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42 Cards in this Set
- Front
- Back
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kinds of skull fractures
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simple - linear
comminuted - multiple fractures depressed - basilar - at base of skull |
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clinical manifestations of skull fractures
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- pain is localized and persistent
- basilar fractures --- produces hemorrhage in nose and ears ----- battle's sign and halo sign |
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ecchymosis behind ear
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- battle's sign
- an indicator of basilar fracture |
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halo sign
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- ring of CSF around blood stain from drainage
- indicator for basilar fracture |
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When should you suspect a brain injury?
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- Altered LOC, confusion
- neurological changes - pupillary changes, absent gag and corneal reflex - changes in VS, hypothermia, altered respiratory pattern, brady or tachycardia - Headache, seizures |
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types of brain injuries
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- concussion - temporary brain function without any structural damage
- temporary loss of consciousness and memory lapses - contusion - more severe than concussion, possible localized damage - loss of consciousness, stupor and confusion - diffuse axonal injury - more widespread damage, especially to axons, often producing prolonged comas - hematoma - collection of blood in brain |
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concussion
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= temporary loss of brain function w/o structural damage
mild - LOC <30 min - memory lapse classic - LOC <6h, amnesia |
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nursing concussion
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- instruct family to observe SS and report immediately!
- difficulty awakening/speaking - confusion - severe HA - vomiting - hemiplegia |
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kinds of hemorrhage
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- epidural
- subdural - intracerebral - outside dura, inside dura, within brain |
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epidural hematoma
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- EMERGENT - MAY GO INTO RESP ARREST
- brief Loss of C, return to lucid state - body able to compensate for growing hematoma during lucid state, no inc ICP - decompensation, inc ICP, respiratory arrest |
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hematoma treatment
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burr holes and craniotomy - remove clot and relieve pressure
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subdural hematoma
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acute
- symptoms develop 24-48h subacute - symptoms develop 48 - 2 weeks chronic - often found in elderly - minor head injuries cause symptoms much later on - 3 weeks to months later - often mistaken for stroke - clot calcifies, producing come and go HAs, peronality changes, mental detoriation |
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intracerebral hematoma
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- craniotomy and craniectomy may not be possible due to location
- supportive treatment - control ICP - careful fluids - antihypertensive meds |
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what brain injury is emergent for respiratory depression
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- epidural hematoma
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important questions to ask after a traumatic brain injury
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- when did injury occur?
- what caused the injury? - what was the direction and force of blow? - was there a loss of consc - how long? - was patient arousable? |
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hematoma treatment
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burr holes and craniotomy - remove clot and relieve pressure
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subdural hematoma
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acute
- symptoms develop 24-48h subacute - symptoms develop 48 - 2 weeks chronic - often found in elderly - minor head injuries cause symptoms much later on - 3 weeks to months later - often mistaken for stroke - clot calcifies, producing come and go HAs, peronality changes, mental detoriation |
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intracerebral hematoma
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- craniotomy and craniectomy may not be possible due to location
- supportive treatment - control ICP - careful fluids - antihypertensive meds |
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what brain injury is emergent for respiratory depression
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- epidural hematoma
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important questions to ask after a traumatic brain injury
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- when did injury occur?
- what caused the injury? - what was the direction and force of blow? - was there a loss of consc - how long? - was patient arousable? |
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how to assess for response to stimuli or deterimine level of consciousness
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glasgow coma scale
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what does glasgow coma scale test for?
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- tests how well a pt responds to stimuli
- eye opening response, verbal response, and motor response |
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How to use Glasgow Coma Scale
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- ranges from 3 (deep coma) to 15 (normal)
- if less than 8, intubate - numbers go low to high, from head to toe - 4 eyes - jackson 5 - v-6 engine |
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What score indicates coma in Glascow Coma Scale?
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less than 8
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signs of increasing ICP
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- bradycardia
- inc BP - hyperthermia, hyperglycemia - Cushing's reflex - widening of pulse pressure - inc RR |
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how to ensure adeuquate respirations in pt with TBI
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- elevate HOB 30 deg - drains oral secretions and dec ICP
- suctioning pulm secretion prevents coughing, which inc ICP - monitoring ABG, potential for ARDS |
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How should a nurse ensure safety for an anxious/resistant patientthat is at risk for self injury?
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- avoid restraints, since pulling against them may increase ICP
- instead, use padded side rails and mittens |
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this drug often crystallizes
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- osmitrol/mannitol
- osmotic diuretic often used for inc ICP and TBI - use warm water to melt |
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TBI affect in body temp
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- hyperthermia
- treat with acetaminophen and cooling blankes - avoid shivering bc it increases metabolic need and inc ICP |
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seizures and TBI
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- TBI increases risk of seizures
- seizures may increase ICP and dec oxygen, so antiseizure meds may be given |
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spinal cord injury background
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- primary injury is the initial trauma
- secondary injury is result of ischemia, hypoxia, and hemorrhage that destroys the nerve tissues - secondary injuries are reversible/preventible during first 4-6h after injury - may be painless |
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What kinds of spinal cord injuries are associated with respiratry dysfunction?
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- C4 - may damage phrenic nerve, which stimulates the diaphragm
- T1 - T11- abdominal and intercostal muscles |
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emergency management of SCI
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- anyone in MV accident, diving, sports injury, fall, or head trauma must be assumed to have SCI until it is ruled out
- which means they must have spine immobilized (spinal board) - prevent twisting movement to prevent vertebra from cutting into cord |
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transection of what vertebrae leads to tetra or paraplegia
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tetraplegia - cervical (C8 or above)
paraplegia - thoracic or below (T1 or below) |
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Cushing's reflex
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widening of pulse pressure in response to increase in ICP
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spinal vs neurogenic shock
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- both are sequelae of SCI
spinal shock - absent reflexes (areflexia), and flaccid, paralyzed muscles below level of injury - reflexes causing bladder and bowel effected (paralytic ileus) - treated with intestinal decompression neurogenic shock - loss of autonomic function below level of injury causes peripheral vasodilation resulting in decrease BP, HR, and CO due to pooling - lack of symp activity impedes perspiration, risk for fever |
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spinal shock treatment
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- spinal shock causes areflexia, commonly in intestines
- results in abdominal distention and paralytic ileus - treatment is intestinal decompression via NG tube |
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what are acute complications of spinal cord injury
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- spinal chock
- neurogenic shock - DVT |
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patho autonomic dyreflexia
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- pain stimuli, usually distended bladder, constipation, or skin attempts to send pain signals up spinal column
- SC lesions above T6 will impede signal - jumps onto autonomic tract, causing autonomic responses - inc BP, diaphoresis - also HA, nausea, nasal congestion, bradycardia - may occur years after injury |
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stimuli of autonomic dysreflexia
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- most commonly distended bladder
- but also constipation, and painful stimuli on skin, cold air |
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management of autonomic dyreflexia
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- place in sitting position immediately to relieve BP
- empty bladder - examine for fecal masses, examine for causes of skin stimuli - if this does not relieve, ganglionic blocking agent Apresoline IV (hydralazine hydrochloride) |
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Assessment of SCI
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- monitor respirations and breathing pattern
- lung sounds and cough - changes in motor or sensory function - assess for spinal shock - monitor for bladder retnetion or distention, gastric dilation, ilieus - temperature, potential hyperthermia |
