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43 Cards in this Set
- Front
- Back
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The scalp "bursts" when it's pinched between the skull and another object
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Scalp lacerations
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What is the DEFICIENT ENZYME in Krabbe's disease?
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beta-galactosidase/galactocerebrosidase
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Easily recognized type of external head trauma
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Scalp Laceration
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List the three types of skull fractures
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1- linear or depressed
2- simple comminuted or compound 3- open or closed |
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A basilar skull fracture occurs where?
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base of skull
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Common facts about manifestations of a skull fracture
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evolve over time
vary with location may include cranial nerve damage Battle's sign ( postauricular ecchymosis) |
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Complications of skull fractures
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infection
hematoma meningeal and brain tissue damage |
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CSF leakage
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Rhinorrhea and otorrhea
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Halo Test
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catch fluid on cloth, blood will condense in center and CSF will form a halo around blood
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Tests for glucose in leaking fluid
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Dextrostix or Tes-Tape
(Glucose will be present in CSF) |
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Concussion red flags
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(swish) seizures, weakness, irritability, slurred speech, head ache
(crud) confusion, repeat vomiting, unusual behavior, drowsy (lin) loc, increasing confusion, neck pain |
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What is a contusion?
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bruising of the brain
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Minor head trauma
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concussion
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Major head trauma
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contusion
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high impact head injury
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contusion
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What delayed responses are seen with contusions
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hemorrhage
hematoma formation seizures cerebral edema |
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post concussion syndrome can occur
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2 weeks to 2 months after head injury
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bleeding below the dura mater arachnoid layer
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subdural
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arterial bleeding above the dura and inner surface of the skull
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epidural
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Causes of subdural bleeding
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blunt trauma
falls in elderly shaken baby spontaneous anticoagulants |
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causes of epidural bleeding
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associated with skull fracture (often temporal)
shaken baby anticoagulants |
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Slower onset, usually venous, that occurs w/in 48 hrs w/ head ache, decreased LOC, and dilation of ipsilateral pupil if ICP is elevated
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Subdural
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Onset of sub acute subdural hematoma
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2 days to 2 weeks
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Onset of chronic subdural hematoma
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2 weeks to 2 months after injury
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Dx of Subdural
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CT
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TX for subdural
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allow to absorb on own
surgical intervention - burr holes or craniotomy |
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fast onset, usually arterial, occurs w/in a few hrs of injury
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epidural
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Manifestations of epidural hematoma
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unconsciousness
brief lucid intervals decreased LOC head ache nausea - vomiting rapid decline in neurological function |
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Dx of Epidural hematoma
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CT
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Prognosis dependent on?
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size of hematoma
severity of pressure damage |
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Nursing care for Subdural or epidural hematoma pt
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Airway and ABC
O2 per unit policy 2 large bore IV Always suspect head injury and C-S injury unless ruled out control bleeding and assess scalp wound check for other injuries by removing clothes obtain pt Hx |
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Should you put anything in pt ears or nose
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no
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Nursing diagnosis for sub and epi hematoma
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impaired tissue diffusion r/t cerebral edema
acute pain r/t cerebral edema |
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Highly precise form of radiation therapy used primarily to treat tumors and other abnormalities of the brain
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stereotactic
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A cut that opens the cranium. During this surgical procedure, a section of the skull, called a bone flap, is removed to access the brain underneath
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Craniotomy
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Nursing check intervals post op
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q15min for first hr and then qhr after
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true or false - medical asepsis is use post op
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true
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Nursing care for surgery site
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Mark drainage and observe amount, color, odor
assess incision for clear drainage, bulging or redness monitor JP and hemavac |
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Nursing interventions and care post -op
(Alot) |
NPO, IV access, monitor LOC, evaluate rate and rhythm of respiration, Bp, neuro checks,
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HOB position
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30 degrees - spinal involvement and to control ICP
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Why is body alignment and position important?
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prevent skin breakdown
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When the cerebral cortex stops functioning or is irreversibly destroyed
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brain death
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Criteria for evaluating brain death
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Coma or unresponsiveness
absence of brain stem reflexes apnea EEG findings |
