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39 Cards in this Set
- Front
- Back
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what are the most common causes of head injuries |
falls mva (most common) being struck by an object assaults |
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what are the types of head injuries and pathophysiology to brain damage primary injury and secondary injury |
due to initial damage (contusions, lacerations, damage to blood vessels, acceleration/deceleration injury, or due to foreign object penetration)
damage evolves after the initial insult (due to cerebral edema, ischemia, or chemical changes associated with the trauma) |
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scalp injuries |
considered the most benign bleed profusely scalp's blood vessels constrict poorly |
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types of scalp injureies |
abrasion-brush wound contusion-superficial ecchymosis/bruise laceration-tear of the skin of the scalp hematoma-below the skin/blood trapped in the tissues (most serious of scalp injuries) |
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skull fractures |
break in the bones of skull due to trauma can occur with or without damage to the brain |
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types of skull fractures |
linear (straight line fx) comminuted (numerous fragment of bone) depressed (fragments of bone are depressed below the level of the skull) basilar (occur at the base of the skull and allow leakage of CSF from ears and nose) Open vs. closed (open indicates a scalp laceration or tear in the dura) |
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brain injury types |
concussion contusion intracranial hemorrhage |
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concussion |
temporary loss of neurologic funciton no apparent structural damage
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clinical manifestations of concussion |
loss of consciousness - lasts a few seconds to minutes dizziness bizarre behavior mild headche nausea |
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treatment of concussion |
rest and ongoing observation of the following difficulty in awakening difficulty in talking confusion severe headache vomiting weakness on one side of the body |
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Residual effects of concussion |
headache lethargy behavioral and personality disorders memory deficits |
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Contusios definition signs and symptoms severity |
more severe than concussion brain is bruised with possible surface hemorrhage
associated with loss of consciousness for even a short period of time
depends on size of contusion amount of cerebral edema |
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clinical manifestations of conftusions |
loss of consciousness dizziness bizarre behavior mild headache nausea vomiting may appear to be in shock, faint pulse, shallow respirations, cool, pale skin, low BP and temperature, and involuntary loss of bowel or bladder control |
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treatment of contusions and treatment outcome less severe and severe |
depends on the severity of injury observation surgery reduce ICP
residual headaches, vertigo, impaired mental function or seizures
brain damage death |
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Intracranial hemorrhaging |
a hematoma or a collection of blood that develops within the cranial vault the most serious of all brain injuries the hematoma or hemorrhage may be epidural, subdural, intracerebral |
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clinical manifestations of intracranial hemorrhaging (delayed until the hematoma is large enough to cause what)? |
distortion of the brain, herniation of the brain, increase in ICP caused by the expanding hematoma initial loss of consciousness followed by lucid intervals (body compensating by rapidly absorbing CSF and deducting intravascular volume) the system eventually fails |
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Severe clinical manifestations of Intracranial hemorrhaging |
ICP increases increased signs of neurological deterioration deterioration of consciousness, pupillary changes hemodynamic changes (bradycardia, respiratory arrest) |
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Nursing assessment focus of intracranial hemorrhaging |
1.) begin with the history of the injury 2.) symptoms (depend on location and severity of the injury) 3.) pain or no pain (persistent and localized usually a fracture, headache, severe injury may show no pain) 4.) location (an example is the basilar location which causes leakage of CSF and is usually very serious due to a greater possibility of infection (meningitis), are fractures that transverse the paranasal sinus or the middle ear, produce hemorrhaging from (nose, pharynx, ears) |
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physical exam of intracranial hemorrhaging |
LOC and ability to follow commands VS (brady/tachycardia, hyper/hypotension, Apnea/SOB, Hypo/hyperthermia) pupillary changes gag reflex spasticity vertigo seizures cns deficits (sensory and motor)
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Diagnostics tests for intracranial hemorrhaging |
x-rays for fractures CT/MRI (better visualization/non invasive), accurately detect the injuries (presence, location, nature, extent of brain involved) (more serious or late findings - cerebral edema, hematomas, infarctions, hydrocephalus) |
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Signs and symptoms of ICP |
altered LOC projectile vomiting widening pulse pressure bradycardia hyperthermia unequal pupils |
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What medical and surgical treatment does the nurse anticipate for the patient |
CT scan to locate the bleed surgery to evacuate and stop the hemorrhage decrease ICP labs (CBC, coagulation profile, renal/metabolic profile, type and cross, ETOH level) |
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What nursing interventions should nurse provide |
Maintain a patent airway monitor for changes in neuro status decrease intracranial presssure provide seizure precautions |
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chronic subdural hematoma most common group is it presented in? |
most common type of injury for geriatrics |
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why subdural hematoma in elderly |
due to brain atrophy secondary to aging allows even a mild head injury to shift the contents of the brain increased likelihood of falls also alcoholics due to frequent falls mortality is high (secondary to brain damage) |
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chronic subdural hematomas |
can develop from seemingly minor injuries time between injury and symptoms can be 3 weeks to months can mimic the S&S of a stroke |
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Clinical manifestations of subdural hematoma |
bleeding is less profuse and body absorbs clot symtpoms fluctuate mistaken for (dementia, psychotic changes)
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Medical management of chronic subdural hematoma |
observation stabilization reduce ICP medications surgery |
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Medications ofchronic subdural hematoma |
osmotic diuretics (mannitol) diuretics (lasix) barbiturates (phenobarbital) anti inflammatory agents (steroids) anticonvulsants (high risk for seizure activity) antibiotics |
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Intracranial surgery |
burr holes (relieve pressure) craniotomy debridement reduction in intracranial pressure removal of fluid/embolic tissue shunting of CSF repair of vessels |
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Nursing management/observation and assessment for what |
LOC pattern of respirations Pupils eye movement facial symmetry swallowing/gag reflex bilateral hand and foot strength airway VS and pulse oximetry reduce ICP fluids/electrolyte imbalances potential injury maintaining body temperature maintaining skin integrity complications |
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Interventions |
LOC VS motor funciton airway fluids/electrolytes imbalances promoting adequate nutrition preventing injury maintaining body temperature maintaining skin integrity improving cognitive functioning |
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brain tumors primary secondary |
localized intracranial lesion originate from cells/structures within the brain originate from cells/structures outside the brain ex. is the metastasis of breast cancer benign or malignant |
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Clinical manifestations of brain tumor three classic signs and other S&S |
Headache vomiting papilledema (edema of optic disk)
visual disturbances (double vision)
localized symptoms (motor cortex = seizure like movements) |
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Medical diagnostic tests and treatment for brain tumors |
CT and MRI
craniotomy chemotherapy radiation palliative (relieves suffering and improves quality of life comfort care) |
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cerebral aneurysm |
blood filled pouches that balloon out from weak spots in the artery wall caused or aggravated by high blood pressure can be congenital aren't always dangerous |
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cerebral aneurysm diagnostic tests |
Hunt-Hess clinical grades (grades according to clinical presentation) CT Cerebral angiography (uses special dye and X-ray to see how blood flows throughout brain) |
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cerebral aneurysm medical management |
bedrest and sedation reduction of vasospasm (calcium channel blockers, volume expanders, IV antihypertensive medications) reduction of ICP craniotomy (clipping, wrapping, bypass) |
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cerebral aneurysm complications |
DVT vasospasm increased ICP seizures hydrocephalus aneurysm re bleeding |
