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43 Cards in this Set
- Front
- Back
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How many points is Glascow Coma Scale based on?
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15 points
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How many points on GCS means pt in a coma?
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7 points or less
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How do you know if drainage from ears or nose is CSF?
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Test for glucose
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How do you want pts HOB with CSF drainage?
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HOB raised 15 to 30 degrees
(once cleared for SC injury) |
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Normal Range for ICP
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10 to 15
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SC injury above C4
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Usually fatal, loss of diaphram, pt needs vent
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If CO2 elevated
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vasodialation of the brain
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If CO2 decreased
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vasoconstriction of the brain
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Lateral hemisection of cord, lesions affect or cut off half of the cord. Ipsilateral motor paryalsis loss of vibratory and position sense.
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Brown-Sequard Syndrome
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What usually causes Brown-Sequard Syndrome?
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Usually a penetrating wound like knife wound or GSW.
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Life threatening syndrome with a cluster of clinical manifestations that result in multiple spinal cord autonomic responses. Responses result from exageratted sympathetic responses to noxious stimuli (ingrown toenail,bladder stone) below the cord region.
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Autonomic Dysreflexia
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Complete motor function loss, lowered pain sensation. Touch,position, and vibration sensation.
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Anterior Cord Syndrome
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Complete lossof skelatal muscle function, bowel and bladder tone, sexual function, and autonomic reflexes. Can'tcontrol temperature. Pt assumes ambient temp.
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Spinal Shock Syndrome
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what indicates shock is resolving in Spinal Shock Syndrome?
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return of reflexes
use of bladder |
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3 days to 3 months after injury aboveT6,spinal shock syndrome presents with
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HA
HTN Bradycardia |
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Nursing interventions for pt with closed head injury are?
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Mannitol Tetanus
Antibiotics Tylenol Pain Management OR Wound Repair Iceto Face |
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Why is it difficult initally to predict the outcome for pt with injury of fx to 4th vertebrae and compression spinal cord?
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Microscopic bleed immediately after injury then edema that spreads the length of the cord, this leads to temp loss of sensation and function which makes it difficult to determine degree of permanent impairment.
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A B C's first, if pt is stable,what comes next?
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D for disability or neuro
LOC,AVPU alert, verbal, pain, unresponsive |
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What is assessed to get a score on a trauma scale?
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Respiratory Rate
Respiratory Effort Systolic Blood Pressure Capillary Refill Glascow Coma Scale |
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Why is a spinal cord injury pt placed on Lovenox?
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To prevent DVT orpossibility of PE
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Closed head injury, VS normal on admission. Changes are noted now.
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Probable epidural hematoma
needs immediate surgical intervention, burr holes |
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Cranial nerve 3,4,6 together look for what?
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"H" eye movement
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Cranial nerves 5 and 7
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Corneal reflex
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Cranial nerve 9 and 10
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gag relex
motor function strength tone coordination |
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How do you check cranial nerve 9 and 10?
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If alert, check against resistance
If comatose, checktongue,flaccid or spastic ROM? |
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C6 spinal cord injury and on a vent. What can you anticipate?
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PARAPLEGIC
Can move head,neck,arms, triceps,and wrists. Complete paryalisis of body and legs. |
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Spinal cord injury, what is it where their body maintains same temperature as environment?
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polikicothermia
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Spinal cord injury recieves solumedrol, why?
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Controls spinal cord edema
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Interventions for ptwith IICP
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head at midline
HOB 15 to 30 degrees pressure off neck maintain normothermia minimize or avoid suctioning seizure precautions treat pain NG tube feeding w/ IVPG zantac stool softeners psychosocial (pt & family) |
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Often in elderly, alcoholics, falls. Has steady decline in LOC
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subdural hematoma
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repid decline in LOC
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epidural hematoma
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What type of head injury is bruising to mastoid process and periorbital eccymossis?
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Basaliar Head Injury
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Why is nasopharyngeal airway contraindicated in basaliar injuries?
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Can goup into the brain instead of into the stomach.
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Abnormal posturing that is poorest prognosis in head injury?
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bilateral flaccid
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complete loss of skelatal muscle function, and autonomic reflexes. Loss of venous return and hypotension, hypothoulmas cannot control temperature.
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Spinal Shock
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What is purpose of back board?
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Immobilization
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Normal ICP range
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10 - 15
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a serious complication of increased ICP
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Cushing's Triad Reflex
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arms flexed
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decrebrate
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everything extended
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decerebrate
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body relaxed
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flaccid
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coup contracoup
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forward injury through back to brain
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volume of one increases decrease must happen in the other or overall ICP occurs
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Monroe-Kellie hypothesis
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