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29 Cards in this Set

  • Front
  • Back
What signifies Head trauma?
craniocerebral head trauma,includes alteration in LOC.
What is a linear skull fracture?
thin line on x-ray,imp only if brain damage
What is a depressed fracture?
injures the brain by bruising it or by driving bone fragments into it, may be palpated and seen on xray
surgical intervention within 24 hours if it is deep as skull
What is a basilar fracture?
occurs in bones over the base of the frontal and temporal lobes, rarely seen on xray. May not have sx
What are clinical signs of Skull Fractures?
CSF drainage from ear or nose - check chem strip-glu
Blood behind eardrum
Periorbital ecchymosis -raccoon eye.
Bruise over mastoid-Battles sign
vision or hearing loss
facial paralysis
What is a concussion?
head trauma that may result in a loss of consciousness for five minutes and retrograde amnesia. No break in skull or dura and no visible damage on ct or mri
What are the sx of concussion?
client presents with headache, dizziness, nausea and vomiting. amnesia correlates with severity of concussion
What is a contusion?
more extensive damage than concussion. damage to brain itself. causing mult. areas of petechial and punctate hemmhorages and bruised areas.
What is a coup injury?
Occur immediately at the point of impact.
What is a contrecoup injury?
When a blow causes injury onthe opposite side of the brain. French for reverse blow
what is a diffuse axonal injury?
results in anatomic disruption of the white matter may result from serious contusions
What are the manifestations of contusions?
Cervical fractures, Secondary effects - cerebral swelling and edema and IICP and herniation syndrome.
How do you assess cerebral contusions?
They vary depending on area affected. May be agitated,and confused(temp. lobe), Hemiparesis(frontal), or Aphasic (frontal-temporal)
How do you assess a brain stem contusion?
Altered LOC-lasts several hour to days to weeks.
Respirations may be normal,ataxic(staggering), periodic or rapid
Pupils are usually small equal and reactive.
Loss of normal eye movements. Doll's eyes-eyes fixed when head turned.
Brain stem contusion Assessment continued
Client may respond to light or noxious stimuli by purposeful movement(pushing it away)or unpurposeful mvmt(decorticate/decebrate)
High Temp, rapid pulse, sweating if hypothalmus is involved.
How would you assess a contusion diagnostically?
xray for fractures
CT for bleeding or brain shifts.
LP for bleeding within subarachnoid space.
How would you medically manage a wound or a fx?
open wounds - covered with pressure-don't remove foreign body.
simple fx - elevate any depressed bone and repair of dura if lacerated.
Compound fx - tx surgically, debrided,cleansed and foregn body removed.
How do you manage a severe HI?
Recognize and treat hypoxia and acid base problems that can contribute to cerebral edema which can increase ICP
Stabilize other conditions-shock/hemorrhage.
How would you manage pharmacologically?
Iv dil, corticosteriods,solumedrol, cimetadine,histamin antagonist,codeine for ha,antibiotics,mannitol, fluids be careful not to overhydrate use cvp and output. Tpn watch bs. Do not mix IV dil with dextrose and H20,
How would you manage dietary considerations
NPO until peristalsis returns commonly 5 days,NG tube increase metabolic, tpn can cause cerebral anoxia.
what is included in the Glasgow Coma Scale?
Loc and responsiveness
Pupils diameters and response to light PERRLA
vital signs
motor strength
reaction to stimuli
response to commands
where is the best place to find a nursing intervention on Head Injuries?
Checkout Nursing Care Plan in the med surg book
What are other interventions?
Risk for CSF leak,meningitis,infection,and DI,
Test all clear liquid for glucose.
Observe for Halo sign-dries in concentric rings
Strict I/O polyuria
Sodium altered as well as osmolarity
aseptic technique-prevention of CNS infections.
what are some complications with head trauma?
hemmorage with hematoma formation
secondary brain swelling and edema
carotid artery occlusion
what are some early complications?
epidural hematoma
subdural hematoma
intracerebral hematoma
what do you do for a hematoma?
Drain it and evacuate it.
Explain Cerebral Perfusion Pressure.
CBF is the amount of Blood in mm passing thru 100g of brain tissue per minute. CPP is the pressure needed to ensure blood flow to the brain.
CPP is equal to MAP minus ICP
Normal CPP is 70-100mmhg. at least 50-60 is needed for adequate perfusion, 30mmhg incompatible with life. 1492
What is increased intracranial pressure?
the pressure exerted on the cranium by its contents.
pressure measured via the CSF-normal pressure 5-15mmhg
Sustained ICP>20mmhg is called malignant cranial htn.
pressure in the lumbar region LP may not reflect ICP flow between brain and sp.cord may be obstructed,but ICP very high
When is the best time to intervene?
Between cranial insult and IICP