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23 Cards in this Set

  • Front
  • Back

What does "Head Injury" apply to?

Scalp, skull, brain

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

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

A manifestation of a scalp wounds?

Heavy bleeding




Be careful for infection!

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)

Battle's sign?

Ecchymosis (bruising) behind the ear

Halo sign?

A ring of fluid around the blood stain on clothes/pillow




This is CSF

What general manifestations will someone with a head injury have?

Altered LOC


Pupil abnormalities


Change of vitals


Headache


A sudden onset of neurological impairments

What is a closed brain injury?

Dura is not broken




Blunt trauma makes brain accelerate then decelerate, damaging brain tissue

What is an open brain injury?

An object penetrates the brain




The scalp and skull will open

What is a concussion?

Temporary loss of consciousness with no structural damage in the brain

What is a contusion?

A more severe injury with possible bleeding




*Cerebral edema can occur which can increase ICP

Diffuse axonal injury?

Axon damage in the brain




Patient will experience a coma

3 types of intracranial hemorrhages (hematomas)?

Epi/extradural: Between skull and dura




Subdural: between dura and brain




Intracerebral: within the brain

What is a PET scan?

Position Emission Tomography:




Will help diagnose a condition and can show us how a condition is developing

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

How can we help with the brain and prevent secondary injury?

Treat the cerebral edema (Mannitol)


Maintain cerebral perfusion


Maintain oxygen


Maintain electrolytes

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

On the Glasgow Coma Scale, what is a score of 14-15?

Minor



A score of 9-13?

Moderate impairment

A score of 8 or less?

Severe impairment

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

What is a posey mitt?

A mitt placed on people to avoid self-injury