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23 Cards in this Set
- Front
- Back
What does "Head Injury" apply to? |
Scalp, skull, brain |
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What is a primary head injury? |
An injury that occurs due to the initial damage So like, contusion, laceration, foreign objects penetrating skull, damage to the blood vessels |
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What is a secondary head injury? |
The damage of a head injury that evolves after the initial insult So cerebral edema, ischemia, chemical changes in the brain |
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A manifestation of a scalp wounds? |
Heavy bleeding Be careful for infection! |
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Manifestations of a skull fracture? |
Localized and persistent pain Fractures at the base of the skull Bleeding from the nose, ears, or pharynx Battle's or Halo sign (characteristic to base fracture of skull) |
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Battle's sign? |
Ecchymosis (bruising) behind the ear |
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Halo sign? |
A ring of fluid around the blood stain on clothes/pillow This is CSF |
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What general manifestations will someone with a head injury have? |
Altered LOC Pupil abnormalities Change of vitals Headache A sudden onset of neurological impairments |
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What is a closed brain injury? |
Dura is not broken Blunt trauma makes brain accelerate then decelerate, damaging brain tissue |
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What is an open brain injury? |
An object penetrates the brain The scalp and skull will open |
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What is a concussion? |
Temporary loss of consciousness with no structural damage in the brain |
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What is a contusion? |
A more severe injury with possible bleeding *Cerebral edema can occur which can increase ICP |
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Diffuse axonal injury? |
Axon damage in the brain Patient will experience a coma |
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3 types of intracranial hemorrhages (hematomas)? |
Epi/extradural: Between skull and dura Subdural: between dura and brain Intracerebral: within the brain |
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What is a PET scan? |
Position Emission Tomography: Will help diagnose a condition and can show us how a condition is developing |
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What should we ALWAYS assume about a head injury until it is proven otherwise? |
We always assume the cervical spine is injured We do a C spine xray to rule out |
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How can we help with the brain and prevent secondary injury? |
Treat the cerebral edema (Mannitol) Maintain cerebral perfusion Maintain oxygen Maintain electrolytes |
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Why might someone with a head injury have fluctuating body temperatures? |
There could be damage to the brain stem The hypothalamus is located in the brain stem, where body temperature is controlled |
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On the Glasgow Coma Scale, what is a score of 14-15? |
Minor |
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A score of 9-13? |
Moderate impairment |
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A score of 8 or less? |
Severe impairment |
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What are some big nursing interventions we need to plan for when taking care of someone with a head injury? |
Maintain the airway Maintain cerebral perfusion Nutrition Temp Electrolytes Skin integrity Prevent injury |
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What is a posey mitt? |
A mitt placed on people to avoid self-injury |