Head Injury/Test 3 Flashcards Preview

NSG 2202 > Head Injury/Test 3 > Flashcards

Flashcards in Head Injury/Test 3 Deck (37)
Loading flashcards...
1
Q

Head injury

A

*any trauma to scalp, skull or brain. Primarily signifies craniocerebral trauma, including an alteration in consciousness.

2
Q

Poor outcomes of head injuries:

A

presence of an intracranial hematoma; increasing age of the patient; abnormal motor responses; impaired or absent eye movements or pupil light reflexes; early sustained hypotension, hyoxemia, or hypercapnia; ICP levels are higher than 20 mm Hg

3
Q

Major head trauma: Contusion-

A

bruising of the brain tissue within a focal area. Develops areas of hemorrhage infarction necrosis and edema.

4
Q

Contusion: Coup is

A

site of direct impact

5
Q

Contusion: Countrecoup

A

(secondary) injury caused by movement of the brain inside the skull.

6
Q

Laceration is

A

actual tearing of brain tissue and often occurs in association with depressed and compound fractures and penetrating injuries. Tissue damage is severe and surgical repair is impossible because of the texture of the brain tissue.

7
Q

Delayed responses of laceration:

A

Hemorrhage, hematoma, formation, seizures and cerebral edema

8
Q

Head Injury: Pathophysiology:

A

Widespread axonal damage occurring after a mild, moderate or severe TBI. Increasing evidence that axonal damage is not preceded by an immediate tearing of the axon from the traumatic impact, but rather the trauma changes the function of the axon, resulting in axon swelling and disconnection. Takes approximately 12-24 hours to develop and may persist longer.

9
Q

S/S of head injury

A
  • decreased LOC
  • increased ICP
  • decerebration or decortication
  • global cerebral edema
10
Q

Complications of head injury:

A

epidural hematoma (bleeding between the dura and inner surface of the skull; neuro emergency.

11
Q

S/S of complications of head injury:

A
  • Unconscious at the scene.
  • HA
  • N/V
  • Focal findings
  • Subdural hematoma (bleeding between duramater and arachnoid layer of menigeal covering of the brain.) usually venous in origin, slower to develop large enough to produce symptoms
12
Q

Subdural hematoma: Acute

A
  • 24-48 hr after severe trauma
  • Immediate deterioration
  • Craniotomy, evacuation and decompression
13
Q

Subdural hematoma: Subacute

A
  • 48 hr-2 week after severe trauma
  • Pt will show lethargy and will only open eyes to shaking and loud voices calling their name.
  • Initial unconsciousness, gradual improvement, deterioration over hrs, dilation of pupils and ptosis.
  • Evacuation and decompression
14
Q

Subdural hematoma: Chronic

A
  • Weeks to months, ususally >20 days after injury; often injury seemed trivial or forgotten by patient
  • Nonspecific, nonlocalizing progression; progressive alteration in LOC
  • Evacuation & decompression, membranectomy
15
Q

Scalp lacerations:

A

Most minor type of head trauma (many blood vessels with poor constrictive abilities)

16
Q

Scalp lacerations: Major complication:

A

Infection

17
Q

Skull fractures:

A
  • Linear depression
  • Simple
  • Closed or open
18
Q

Assessment for CSF leakage:

A
  • Testing to determine if leakage is CSF:
  • color
  • appearance
  • amount of leaking fluid must be noted because both of these tests can give false-positive results
19
Q

Diagnostics for cerebral spinal fluid leakage (CSF);

A
  • Dextrostix or Test-tape (positive for CSF leak)

* “lalo” or “ring” sing if the drainage is bloody, place on white dressing to see if there is a halo

20
Q

Head injury: Minor head trauma

A

Concussion

21
Q

Concussion:

A

a sudden transient mechanical head injury with disruption of neural activity and a change in LOC. May not lose total consciousness.

22
Q

Post concussion syndrome:

A

Two weeks to two months post injury. Persistent headache, lethargy, personality and behavioral changes, shortened attention span, decreased short term memory, changes in intellectual ability. Can significantly affect patient’s abilities to perform activities.

23
Q

Head injury: Major head trauma

A
  • Contusion

* Laceratiion

24
Q

Epidural Hematomas:

A
  • bleeding between the dura and inner surface of the skull; neuro emergency depending on size
  • a collection of blood between the skull and the dura
  • commonly associated with temporal and parietal fractures
  • S/S unconsciousness at the scene, headache, n/v, focal findings
25
Q

Epidural Hematomas: Hallmark sign

A

*Transient LOC followed by lucid period then rapid neurological decline, unconsciousness at the scene.

26
Q

Symptoms of epidural hematomas:

A
  • Severe headache
  • Focal findings
  • N/V
  • Sleepiness
  • Dizziness
  • Contralateral hemiparesis or hemiplegia
  • Abnormal posturing
  • Pupillary changes in S/S unconsciousness at , n/v, focal findings
27
Q

Subdural Hematoma is:

A
  • Bleeding beneath dura mater
  • Usually venous in origin, slower to develop a large hematoma to produce symptoms
  • From rupture of bridging veins
  • Focal brain injuries from acceleration or deceleration forces
  • Slower bleed
  • Accute <48 hours or chronic
28
Q

Subdural hematoma: High Risk Patients:

A
  • Elderly
  • Anticoagulation
  • Chronic alcohol users
29
Q

Subdural Hematoma: Acute

A
  • Elderly
  • Trips and falls
  • strikes head
  • 2 days later is confused
  • Reported by family to be “acting funny”
30
Q

Subdural Hematoma:

Chronic

A
  • Elderly person
  • Normal cerebral atrophy
  • Bridging vessels stretched
  • Leads to leaking
31
Q

Head Injury: Diagnostic studies and collaborative care:

A
  • CT considered best diagnostic test
  • MRI; PET; evoked potentials; transcranial doppler, cervical spine x-ray, Glascow Coma Scale
  • Teaching guide
32
Q

Nursing Management: Head Injury: Assessment-

A
  • Glascow coma scale (potential for IICP)

* Presence of CSF leak

33
Q

Nursing Management Head Injury: Diagnosis

A
  • Ineffective airway clearance r/t decreased LOC, immobility and inability to mobilize secretions as manifested by ineffective cough, inability to clear secretions, crackles on auscultation, thick secretions.
  • Ineffective tissue perfusion (cerebral) r/t cerebral edema as manifested by Glasgow Coma Scale 20 mm Hg, 10 lb (4.5 kg), abrasions or lacerations.
34
Q

Nursing Management: Head Injury Planning

A
  • Head injury vs. IICP
  • protection of CS leak sites
  • Positioning
  • Avoidance of NG tubes/nasotracheal suctioning
  • Protection from injury
35
Q

Nursing Management: head injury: Implementation-

A

*Long term mental/emotional problems (>6 hrs comatose, personality change) loss of concentration & memory with defective memory processing; personal drive may decrease; apathy & apparent laziness may increase; euphoria and mood swings; loss of social restraint , judgment, tact and emotional control

36
Q

Evaluation/expected outcomes:

A
  • Maintain normal cerebral perfusion pressure
  • Achieve maximal cognitive motor and sensory function
  • Experience no infection, hyperthermia, or pain
37
Q

Nursing Management: Treatment

A

*In cases of larger acute subdural hematomas and epidural hematomas or/and associated with significant neurologic impairment, the blood must be surgically removed.