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96 Cards in this Set

  • Front
  • Back
Types of forces
Primary Brain Injury
caused by physical force, open or closed, severity categorized on GCS and LOC
Open Head Injury (penetrating)
most common, results in focal brain injury
Fractures of teh skull
Linear - simple clean break
Deressed - bone pressed into brain
Comminuted - depression of bond fragements into brain
Basilar - found at teh base of the skull
Open Head Injuries can result in
CSF leaking from nose and ears
Hemorrhage from internal carotid, infection, or damage to CN I, II, VII, VIII
Closed Head Injury
Blunt Trauma, dura mater remains intact and brain tissue is not exposed, biggest risk of increased ICP, focal or diffuse brain injuries
Types of closed head injuries
Concussion - brief loss of consciousness no permanent damage
Contusion - bruising of brain tissue.
Laceration - tearing of brain tissue or vesses, more serious than contusion, bleeding
Site of impact, primary injury
Opposite site of injury, secondary injury
Focal Brain Injury
Grossly observable brain lesions, open or closed, Contusions, can lead to epidural, subdural and intracerebral hemorrhage, may be coup or coutercoup injury
Contusion in the Brain Stem
affects the respiratory and cardiac systems
Priority NI for TBI
Assess respiratory system and cardiac system
Diffuse Brain Injury
Blunt force to head, tearing, twisting or spraining neurons, associated with acceleration and deceleration injuries, may be associated with concussion
Direct Blow
By a stick, puck, ball hitting the head, fall where head hits ground
Indirect Blow
Brain crashes into their skull, moving player hits immovable object
Complications of trauma pt
Tissue perfusion problems
Respiratory problems
Unstable clotting factors
Altered body image
Coping Problems
Warning signs after head injury - first 24 hours
Change in LOC, seizures, bleeding or watery drainage from nose or ears, pupils slow to react or unequal, blurred vision, loss of sensation to any extremity, slurred speech, vomiting
Secondary Brain Injury
Injury that is caused after initial injury
Types of secondary brain injury
Increased ICP
Loss of autoregulation
Increased ICP
Prevent ICP to minimilize neural damage, CNS nerves to do not regenerate after Wallerian Degeneration
Types of Hemorrhage
Epidural Hemorrhage
Arterial bleeding in space between dura and the inner skull - very life threatening, short lucid time, increasingly symptomatic
Subdural Hemorrhage
Venous bleeding into space beneath dura and above arachnoid, nighest mortality, occurs more slowly
Subdural Hemorrhage phases
Acute - within 48 hrs
Subacute - occurs between 48 and 2 weeks
Chronic - after 2 weeks to several months
Subarachnoid Hemorrhage
Broken vessels between arachnoid and pia mater, can be from TBI, usually from aneurysm, Worst HA of their life
Intracerebral Hemorrhage
Tearing of small arteries and veins within brain or brain stem
Loss of Auto regulation
Alters blood flow, HTN increased blood flow and ICP
Hypoxemia dn hypercapnia cause vasodialation and increase ICP
Abnormal increase in CSF through dialation of ventricles, or obstruction fo CSF pathway, increases ICP
Don't want to have happen
Shift of brain tissue downward
Type of herniation
Cerebeller tonsillar
Uncal herniation
temporal area nd 3rd cranial nerve. Dialated and unresponsive pupils, ptosis, rapid deterioration
Central herniation
Downward shift of brain stem, pinpoint pupils and Cheyne-Stokes respirations
Celebeller Tonsillar
Respiratory or cardiovascular compromise or arrest
History of TBI
Loss of consciousness, when where, how, seizure, N/V
Kernigs Sign
Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
Brudzinski's Neck sign
Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
Clinical Presentation
Baseline data, VS, neural
Early detection of change in status
Treat as if spinal cord injury intil MRI proves wrong
Airway breathing pattern assessment
Psychosocial assessment
Emotional changes
Change in personal or familydynamics
Care and monitoring necessary
Lab Assessment
for primary TBI none, CT MRI
Lab Assessment for Secondary TBI
ABG, CBC, Serum glucose, serum electrolytes and serum osmolarity
Radiographic Assessment
CT scan - primary what is problem
Radiography of cervical spine and skull bones - to check for fractures - keep support collar in place
CT Scan
ID space occupying lesions, hemorrhage, skull fractures, bran tissue shift
Diffuse axonal injury
Doppler flow and cerebral angiogram
integrity of blood vessels
Evoked potentials
Test the functioning of sensory pathways by CN tests
IP monitoring device
Intraentricular Catheter (IVC) is inserted into lateral ventricle, can test CSF or release CSF if ICP is increased
Monitoring of TBI pt
ICP, lab values, effectiveness of treatment, VS q 1-2 hrs, continuous cardiac monitoring
Positioning of PT with TBI
avoid extreme felxion of neck, logroll client, elevate HOB 30 degress to enhance drainage, preventing increased ICP
Neuro assessment
every 1-2 hours
Pupil response
Every 1-2 hours with neural eheck, gives the test info regarding extent of bleeding or injury, best every 90 minutes to help with REM sleep
Drainage from nose or ear
Collect drainage on white cloth to measure, CSF has bglucose but nasal drainage does not. Halo around blood spot may be CSF
Avoided as cerebral perfusion can be compromised, only if acute neurologic detioration for brief periods
Avoid coughing
Seizure precautions
Barbituate Coma
Uncoltrollable Increases in ICP
Pentobarbital sodium
Decreases metabolic edemands of the brain stabilizing cell membranes, decreasing gasogenic edema, and providing a uniform blood supply.
Barbituate Coma
Requires ventilator and ICP monitoring
Complications of Barbituate Coma
Cardiac Dysrhythmias, hypotension, F&E Imbalances
osmotic diuretic used to treat cerbral edema nd increased ICP by drawng fluid out of brain tissue
How to give mannitol
How do you know mannitol is working
mental status improves
Enhances mannitol therapy, reduces edema, blood volume and production of CSF
Fentanyl or codiene
decrease agitation with ventilator clients
Barbituates (neuromuscular blocking agents)
decrease cerebral metabolism associated with agitation
help prevent seizures
Reduce fever
Fluid and Electrolyte Intervention
I&O monitoring every hour, usually fluid restriction, acute renal failure
Acute Renal Failure
minotor serum osmolarity daily, monitory diuretics, F/C necessary
Diabetes Insipidus and SIADH
TBI pt at risk from damage or compressed pituitary gland or hypothalamus
Can also occur from hypothalamic dysfunction as it regulates serum osmolality
Pulmonary managemetn
Increased and thickened secretions, suctioning, observe client for increasing ICP when suctioning
Behavioral Management
Hand mitts
Restraints used sparingly
monitor frequently (every hour)
Dim lighting and quiet environment
Sensory and perceptual alterations
Changes in senses, at risk for falling, chicking, diorientation, loss of memory, orient client frequently, assure them they are safe, cue within environment (large faced clock, sumple calendar)
anti-thrombotic compression boots, prophylactic anticoagulants, ROM every 2-3 hrs, prevent foot-drop, anti-contracture devices
Nutrition management
daily weight
daily serum albumin
ability to chew or swallow
Supplemental milkshakes if conscious and able to swallow
Eneral feeding
Signs of dehydration
Skin tenting
Dry mucus membranes
Low urine output
Daily Weight
Best indication of fluid depletion or overload
Craniotomy for uncontrolled ICP
All interventions does not decrease ICP, remove ischemic and or tips of temporal lobes to allow for brain expansion without further compromise. Also used to remove epidural and subdural hematomas
Post op Craniotomy
Assess q30 for 4 then q hour until stable for 24 hours, then vitals every 2-4
Post Op Assessment
Breathing and respiratory status, Strict I&O (1500 ml/day), ROM every 2-3 hrs, compression boots
Positioning post op
doctor orders position, start flat and gradually increase HOB to 30 degrees, position on non-affected side, no nick or hop flexion, keep head midline, neutral position
Monitor Craniotomy dressing
Check every 2 hours, mark drainage one each shift for comparison, reinforce dressing prn, document amoutn, color, halo,
What is typical wound drainage
30 ml per shift
Report if > 50 ml to physician
Glascow Coma Score
scored between 3 and 15, 3 is the worst, 15 is the best
Best Eye Response
4 eyes open spontaneously
3 eyes open to verbal command
2 eyes open to pain
1 no eye opening
Best Berbal response
5 oriented
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no verbal response
Best Motor Response
6 obeys commands
5 localizing pain
4 withdrawal from pain
3 flexion to pain
2 extension to pain
1 no motor response
Glascow Coma Scale Evaluated
13 - 15 mild
9 - 12 moderate
3 - 8 severe
<8 pts are in a coma
Types of aphasia
Naming severe - may not be able to name common or high frequency objects (key)
Naming Mild - May only have difficulty naming low frequency objects or parts
Disorder of higher cortical function
Aphasia refers to
an acquired abnormality of language, usually from focal brain lesion
Type of Aphasia is dependent on
location of lesion
How to est Aphasia
test fluency, comprehension, and repetition
Common in all types of aphasia
Difficulty writing, difficulty naming
How to test language
fluency, repetition, comprehension, naming, reading, writing
Brocas Aphasia
Impaired fluency and repitition, compresension is intact
Wernickes Aphasia
Fluency in tact, repitition and comprehension are impaired
Visual Neglect
Lack of attention paid to one hemisphere, failure to id on the left, usually caused by lesions on right frontal or parietal lobes, may fail to recognize left side of pictruresk arm, plate, or dress/shave on left.