Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
90 Cards in this Set
- Front
- Back
|
What are 3 types of head injuries?
|
1.Lacerations
2.Skull fracture 3.Basilar skull fracture |
|
|
What is a depressed skull fracture?
|
When part of the skull is pushed in.
|
|
|
Identify 3 potential signs for Basilar skull fractures.
|
1.SCF leaking from nose and/or ear.
2.Battle's sign 3.Raccoon eyes |
|
|
What is Battle's sign?
|
Post-auricular ecchymosis (bruising behind the ear)
|
|
|
Why is an epidural hematoma a neuro emergency?
|
Because it the epidura contains arterys, therefore the bleeding is arterial.
|
|
|
Why is subdural bleeding not as much of an emergency as epidural?
|
The subdura has a space so the blood has some place to go and it is venous bleeding.
|
|
|
What is the main concern with a CSF leak?
|
There is a risk for bacterial infection.
|
|
|
What influences ICP?
|
*Venous/arterial pressure
*Fluid balance *Posture *Temperature *Blood gases, (esp. CO2) |
|
|
Why is CO2 important pertainig to ICP?
|
CO2 is a vasodialator. This would increase the amount of blood into an area that is already under pressure.
|
|
|
At what level should CO2 be maintained on a patient with a head injury?
|
At the lower level of normal 35.
|
|
|
Will you see hyperreflexes with a head injury?
|
Yes
|
|
|
What are the symptoms of increased ICP?
|
*Change in LOC
*Headache *Vomiting *Visual disturbances *Resiratory changes *VS Changes *Paplledema *Motor/sensory dysfunction *Cranial nerve dysfunction *Changes in reflexes |
|
|
What are some diagnostic tools for a head injury?
|
*MRI, CT, EEG
*ICP Measurement |
|
|
What are some tools used to measure ICP?
|
*Ventriculostomy
|
|
|
What are the goals of nursing management when caring for a patient with a head injury?
|
*Preservation of cerebral perfusion
*Prevent increased ICP *Early identification of neuro changes |
|
|
What assessments should a nurse do with a patient with a head injury?
|
*Glasgow coma scale
*Cushing Triad |
|
|
What three things are you looking at when assessing using the Glasgow Coma scale?
|
1.Eye opening
2.Verbal response 3.Motor response |
|
|
Considering the Glasgow Coma scale, what is the point scale for eye assessment?
|
1-4
|
|
|
Considering the Glasgow Coma scale, what is the point scale for verbal response assessment?
|
1-5
|
|
|
Considering the Glasgow Coma scale, what isthe point scale for motor response assessment?
|
1-6
|
|
|
What are the 3 symptoms of Cushings Triad?
|
1.Increasing systolic pressure and widening pulse pressure
2.Bradycardia 3.Irregular respiratory pattern |
|
|
How many cranial nerves are there?
|
12
|
|
|
What is cranial nerve III?
|
The oculomotor nerve.
|
|
|
What does cranial nerve III control?
|
Moves eye up, down, medial
Opens eyelid Constricts pupil |
|
|
What is cranial nerve IV?
|
Trochlear nerve.
|
|
|
How can you assess the function of cranial nerve IV?
|
Have the patient read or walk down stairs.
|
|
|
Can damaged cranial nerves improve?
|
Yes.
|
|
|
How are cranial nerves and peripheral nerves different in respect to recovery?
|
Only cranial nerves can improve after damaged.
|
|
|
What is cranial nerve V?
|
Trigemminal nerve.
|
|
|
What would a nurse do to assess the function of cranial nerve V?
|
Touch the temples, cheek bones and sides of face and ask if there are any differences in sensation.
|
|
|
When a cranial nerve is damaged on one side of the brain, what side of the body is affected?
|
The same side.
|
|
|
What is the term for the damage occuring on the same side of the body as to the side of cranial nerve damage?
|
Ipsilateral.
|
|
|
What is cranial nerve IX?
|
Glossopharyngeal.
|
|
|
What does cranial nerve IX affect?
|
Swallowing.
|
|
|
What is the best indicator of ICP?
|
LOC.
|
|
|
When, in head injuries, is the peak swelling time?
|
The first 48 hours.
|
|
|
What are you assessing when doing a bedside neuro evaluation?
|
*LOC
*Shert term memory *Reasoning *Concentration *Behavior *Communication *Motor/sensory *Gait *Deep tendon reflexes *Cerebellar signs |
|
|
When assessing LOC, what does a person lose first?
|
Time.
|
|
|
When assessing LOC, what does a person lose last?
|
Person.
|
|
|
What do you ask when assessing LOC?
|
*Their name
*Date, time, season *Location *Who is the person sitting next to them? *Why they are where they are. |
|
|
What three assessments, when assessing neuro, are ongoing?
|
*Concentration
*Behavior *Communication |
|
|
What are some examples of cerebellar signs?
|
*Heel to toe walk
*Touch nose then finger and back again. |
|
|
For neurological alterations, which drives are given IV?
|
Diuretics.
|
|
|
Which diuretic works quickly?
|
Mannitol
|
|
|
How do diuretics work?
|
They cause plasma expansion and an osmotic effect.
|
|
|
How do corticosteroids work?
|
They control edema of tissues.
|
|
|
What are some types of cranial surgery?
|
*Burr Hole
*Craniotomy *Cranioplasty *Stereotaxis *Shunt Prodcedure |
|
|
What is a Burr Hole surgery?
|
There is an opening into the cranium created by a drill. It is done to remove blood beneath dura.
|
|
|
What is a craniotomy?
|
An opening into the cranium with removal of bone flap. This is done to excise a tumor, abscess, clot, lesion, or to relieve ICP.
|
|
|
What is cranioplasty?
|
The repair of cranial defect r/t trauma. Artificial material may replace lost bone.
|
|
|
What is stereotaxis?
|
This isused for biopsy or radiosurgery.
|
|
|
What is a shunt procedure?
|
Redirects CSF via a tube from ventricle to abdomen.
|
|
|
List some nursing interventions post-op.
|
*Neurological assessments
*V/S *Prevent increaced ICP/Positioning *Monitor dressing/incision *Pain management |
|
|
What are two types of brain tumors?
|
1.Primary
2.Secondary |
|
|
What is a primary brain tumor?
|
It originated in the brain.
|
|
|
What is a secondary brain tumor?
|
Metastisises from somewhere else in the body.
|
|
|
What are the majority of brain tumors?
|
Gliomas
|
|
|
What is one of the worst types of brain tumor?
|
Glioblastoma multiforme
|
|
|
What glioma grade is a glioblastoma multiforme?
|
A glioma grade 4.
|
|
|
What is the prognosis for a patient with a glioblastoma multiforme?
|
Live 1 year with treatment.
|
|
|
What is encephalitis?
|
Inflammation of the brain.
|
|
|
What is meningitis?
|
Inflammation of the lining of the brain (meninges).
|
|
|
Which is the worst kind of infection, bacterial or viral?
|
Bacterial.
|
|
|
What are some symptoms of encephalitis/meningitis?
|
*Headache
*Nausea/vomiting *Nuchal rigidity *Photophobia *Seizures *Coma *CSF cloudy with high WBC and protein and low glucose. |
|
|
What are the causes of encephalitis/meningitis?
|
*Open skull fractures or drains.
*Cranial surgery *May follow an uper resp infection especially streptococcus. *West Nile/St. Louis or other virus *Mosquitoes and ticks *Rubella |
|
|
What type of spinal injuries are there?
|
Skeletal and cord.
|
|
|
What is skeletal injury of the spine?
|
Damage to the vertebral bones and ligaments.
|
|
|
What is neurological injury of the spine?
|
Cervical, thoracic, or lumbar.
|
|
|
Above what cervical location would an injury result in use of a ventilator?
|
Any damage above C4.
|
|
|
What is the result with a cervical injury?
|
Quadriplegia.
|
|
|
What ist he result with a thoracic/lumbar injury?
|
Paraplegia.
|
|
|
What does a patient with quadriplegia use to breath if not on a ventilator?
|
Their diaphragm.
|
|
|
At what location does the cord end?
|
L2.
|
|
|
What is spinal shock?
|
Temporary loss of sensation, about 2-8 weeks. Then there are reflexes.
|
|
|
Can a patient with a spinal injury above L2 still have reflexes to the bowel and bladder?
|
Yes
|
|
|
Identify some nursing assessments to be completed with spinal injury.
|
*Motor/sensory
*Bowel/bladder *Respiratory *Cardio-vascular *Otrho *Sexuality *Psychiatric *Lifestyle |
|
|
What is autonomic Dysreflexia?
|
A severe cardiovascular reaction.
|
|
|
What are the s/s of autonomic dysreflexia?
|
*Throbbing headache
*Decreased heart rate *Severely elevated BP *Nasal congestion *Sweating/flushing above the lesion *Anxiety *Blurred vision |
|
|
What is a basilar skull fracture?
|
It is a linear fracture that occurs when the fracture involves the base of the skull.
|
|
|
What is a potential sign of a CSF leak?
|
Infection.
|
|
|
What is a concussion?
|
A sudden transient mechanical head injury with disruption of neural activity and a change in the LOC.
|
|
|
What is a contusion?
|
The bruising of the brain tissue within a focal area.
|
|
|
What is a diffuse axonal injury (DAI)?
|
Widespread axonal damage occurring after a mild, moderate, or severe TBI (traumatic brain injury).
|
|
|
Why is it important to place a patient with ICP in the semi-fowlers position?
|
This enhances respiratory exchange and aids in decreasing cerebral edema.
|
|
|
What is demonstarted in the Monro-Kelly chart?
|
The relationship of pressure to volume, in regard to ICP.
|
|
|
What is Cushing's triad?
|
1.Systolic hypertension with a widening pulse
2.Bradycardia 3.Altered respirations |
|
|
What is hemiplegia?
|
Paralysis affecting only one side of the body.
|
|
|
What is Uncal herniation?
|
There is a lateral and downward herniation.
|
|
|
What is dysphagia?
|
Difficulty swallowing.
|
|
|
What is hyperreflexia?
|
Overresponsive reflexes.
|
