head injuries

Question 1

open head injury

Answer 1

the integrity of the skull is compromised by either a penetrating object or blunt force trauma.

Question 2

closed head injury

Answer 2

occurs from blunt trauma

Question 3

head injuries classified as

Answer 3

mild, moderate, or severe, depending upon Glasgow Coma Scale ratings and the length of time the client was unconscious.

Question 4

concussion

Answer 4

occurs after head trauma that result in a change in the client’s neurological function and usually resolves within 72 hr.

Question 5

post concussion syndorme

Answer 5

includes persistence of cognitive and physical manifestations for an unknown period of time.

Question 6

contusion

Answer 6

brain is bruised and the client has a period of unconsciousness associated with stupor and or confusion.

Question 7

diffuse axonal injury

Answer 7

widespread injury to the brain that results in coma and is seen in severe head trauma.

Question 8

head injuries clinical findings

Answer 8

• Presence of alcohol or illicit drugs at time of injury.
• Amnesia (loss of memory) before or after the injury.
• Loss of consciousness: Length of time the client is unconscious is significant.
• CSF leakage

Question 9

cfk leakage from nose

Answer 9

can indicate a basilar skull fracture (“halo” sign: yellow stain surrounded by blood on a paper towel; fluid tests positive for glucose).

Question 10

intracranial hemorrhage

Answer 10

• can occur in the epidural, subdural, or intracerebral space.
• It is a collection of blood following head trauma.
• There can be a delay of weeks to months in presenting manifestations for a subacute or chronic subdural hematoma.

Question 11

skull fractures: what should the nurse be alert for

Answer 11

• can occur following forceful head injury.
• The nurse should be alert for drainage from the ears or eyes (cerebral spinal fluid [CSF]).
• A cervical spine injury must be ruled out prior to removing any devices used to stabilize the cervical spine.
• Occur frequently with head trauma.
• Location determines clinical manifestations.

Question 12

epidural hematoma

Answer 12

• Bleeding between the dura and skull.
• Neurologic Emergency
• Associated with a fracture crossing a major artery.
• Needs Rapid Surgery bc artery bleeding

Question 13

Subdural Hematoma

Answer 13

• Bleeding between dura and arachnoid layer of meninges.
• Venous bleed, slow to develop. (can take up to 2 days)

Question 14

basilar skull fractures

Answer 14

• Linear fx at base of skull
• Battles Sign (Raccoon eyes)
• Tear in the dura and CSF leakage from ear and nose.
• Test drainage for glucose
• DO NOT INTRODUCE NGTUBE IF BASILAR FX IS SUSPECTED!!!
• Major complication is infection
• Meningitis

Question 15

Decerebrate posturing

Answer 15

• Arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar flexion of the feet.

Question 16

Decorticate posturing (flexor)

Answer 16

internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers.

Question 17

family care

Answer 17

• Support of the family following head injury is of great importance.
• The Brain Injury Association of America provides families and clients with information needed to cope with this potentially devastating injury.
• The family can face difficult decisions following head injury.
• If brain death has occurred, the family needs support when deciding whether to donate organ

Question 18

care of a head injury

Answer 18

Respiratory status (the priority assessment):
- The brain is dependent upon oxygen to maintain function and has little reserve available if oxygen is deprived.

• Untreated hypoxia leads to brain injury or death if the brain has been denied adequate oxygenation for 3 to 5 min.
• Changes in level of consciousness, using the Glasgow Coma Scale (GCS), provide the earliest indication of neurological deterioration.

Question 19

cranial nerve function

Answer 19

Eye blink response, gag reflex, tongue and shoulder movement

Question 20

assess eyes for

Answer 20

pupils for size, equality, and reaction to light: Pupils that are equal, round, and react to light and accommodation (PERRLA) are a normal finding.

Question 21

factors that influnce intracranial pressure

Answer 21

• Arterial pressure
• Intraabdominal and intrathoracic pressure (venous congestion)
• Posture
• Temperature
• Blood gases (CO2 levels)

Question 22

normal icp

Answer 22

5 to 15 mm Hg
Elevated if >20 mm Hg sustained

Question 23

normal compensation

Answer 23

• Changes in CSF volume
• Changes in intracranial blood volume
• Changes in tissue brain volume

Question 24

Brain’s ability to compensate is limited If

Answer 24

volume increase continues, ICP rises → decompensation

Question 25

How do you know if your ICP is up?

Answer 25

CT scan MRI EEG Cerebral angiography NO lumbar puncture

Question 26

ventriculostomy

Answer 26

Catheter inserted into lateral ventricle Coupled with an external transducer

Question 27

Manifestations of Increased Intracranial Pressure

Answer 27

- Severe headache, nausea, vomiting - -Deteriorating level of consciousness, restlessness, irritability - Dilated or pinpoint nonreactive pupils - Cranial nerve dysfunction - Alteration in breathing pattern (Cheyne-Stokes respirations, central neurogenic hyperventilation, apnea) - Deterioration in motor function, abnormal posturing (decerebrate, decorticate, flaccidity) -Cushing’s triad Seizures

Question 28

cushings triad

Answer 28

a late finding characterized by severe - hypertension with a widening pulse pressure (systolic – diastolic) - bradycardia - apnea.

Question 29

#1's sign of elevated icp

Answer 29

- Change in level of consciousness - Change in vital signs - Cushing’s triad - Ocular signs (pupils abnormal, unequal, fixed, no movement)

Question 30

ocular sign ICP

Answer 30

Compression of oculomotor nerve - Unequal pupil dilation (BAD) - Sluggish or no response to light - Inability to move eye upward - Eyelid ptosis: eyelid droop down

Question 31

s/s of high icp

Answer 31

Headache - Often continuous - Worse in the morning Vomiting - Not preceded by nausea - Projectile

Question 32

Herniation

Answer 32

- Increased compression of brainstem and cranial nerves. - Forces Cerebellum and brainstem down. - If not resolved, respiratory arrest will occur. - bc of all pressure pushing on brain stem

Question 33

Collaborative Care: Increased ICP

Answer 33

- Treat underlying cause. - Adequate oxygenation +PaO2 > 100 mm Hg +PaCO2 35-45 mm Hg - Intubation - Mechanical ventilation - Surgery

Question 34

Treating Elevated ICP: Medications

Answer 34

mannitol hypertonic saline corticosteroids

Question 35

mannitol

Answer 35

Plasma expansion Osmotic effect: pull extracellular into cells

Question 36

Hypertonic saline

Answer 36

- Moves water out of cells and into blood. - Monitor BP and serum sodium levels.

Question 37

Corticosteroids

Answer 37

Edema surrounding tumors, brain abscesses.

Question 38

pain and anxiety management

Answer 38

- Opioids -Propofol (Diprivan) - Dexmedetomidine (Precedex) - Neuromuscular blocking agents - Benzodiazepines

Question 39

patient positoning

Answer 39

- Elevate head at least 30 to reduce ICP and to promote venous drainage. - Avoid extreme flexion, extension, or rotation of the head, and maintain the body in a midline neutral position. - Maintain cervical spine stability until cleared by an x‑ray. - Implement measures to prevent complications of immobility (turn every 2 hr, footboard, and splints). - Specialty beds can be used.

Question 40

airway management

Answer 40

- Maintain a patent airway. - Provide mechanical ventilation as indicated. - Administer oxygen as indicated to maintain PaO2 - The client can be hyperventilated on mechanical ventilation to decrease ICP. - Brief periods of hyperventilation for the intubated client can be used after the first 24 hr following injury to help lower ICP. - Maintain safety and seizure precautions (side rails up, padded side rails, call light within the client’s reach).

Question 41

fluids high icp

Answer 41

- Monitor fluid and electrolyte values and osmolality to detect changes in sodium regulation, onset of diabetes insipidus, or severe hypovolemia. - Provide adequate fluids to maintain cerebral perfusion and to minimize cerebral edema. - When a large amount of IV fluids are prescribed, monitor for excess fluid volume which could increase ICP. - The client should receive stool softeners and avoid the Valsalva maneuver

Question 42

craniotomy

Answer 42

Opening into skull by removal of bone flap and dura. - Remove lesion/tumor - Drain blood - Relieve elevated ICP

Question 43

burr hole

Answer 43

Opening into skull with a drill. Remove localized fluid and blood beneath top layer dura.