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nsg 410 ms ii (mcp) > Unit 2: Assessment + Interventions for Traumatic Brain Injury > Flashcards

Unit 2: Assessment + Interventions for Traumatic Brain Injury Flashcards

1
Q

How is the severity of a TBI determined? (4)

A
  1. GCS score immediately following resuscitation
  2. Presence (or absence) of brain damage seen on the CT/MRI following the trauma
  3. Estimation of the force of the trauma
  4. Sxs presentation
    (pg. 912)
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2
Q

Diagnostic Tests for a TBI

A
  1. CT
  2. MRI
  3. ICP Monitoring
  4. EEG
  5. Telemetry
  6. Labs: ABG, CBC, CMP, Toxicology screen
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3
Q

What patient history should we obtain r/t a TBI?

A
  1. Info about the event
    -What happened? When? Where? How?
  2. Info after event
    -loss of consciousness? mental state? seizure activity?
  3. Medical History (comorbidities)
    -Seizures, CV, BP, immunocompromised, SUDs
    -Sensory deficits
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4
Q

TBI + Neuro Assessment (6)

A
  1. LOC
  2. GCS
  3. PERRLA
  4. Signs of Increased ICP
  5. Headache
  6. Seizures
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5
Q

TBI + Respiratory Assessment (3)

A
  1. Breathing pattern + RR (Cheyne-Stokes/apnea?)
  2. Hypoxemia? (PaO2); Hyper/hypocarbia? (PaCO2)
  3. Effectively managing airway? (cough/gag reflex?)
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6
Q

TBI + CV Assessment (4)

A

Monitor for Autoregulation impairment!
1. BP
2. HR
3. Pulses
4. Temp

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7
Q

TBI + MS Assessment (4)

A
  1. Mobility (bilateral motor responses)
  2. Brainstem/cerebellar injury
    - Ataxia? Weakness? Rigidity? (muscle tone)
  3. Alteration in sensorium?
  4. Posturing?
    • Decerebrate
    • Decorticate
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8
Q

TBI + GI Assessment

A
  1. Nausea?
  2. Vomiting?
    (late signs of increased ICP!)
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9
Q

Mild, Moderate, or Severe TBI?
GCS: 3-8
Loss of consciousness: + >6 hrs
Imaging: Visible focal + diffuse damage to brain, vessel &/or ventricle damage
S/S: extreme neuro + MS deficits requiring ICU-level of care + ICP monitoring ; temporary or permanent

A

Severe!

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10
Q

Mild, Moderate, or Severe TBI?
GCS: 12-15 (?)
Loss of consciousness: - or + ≦30 min
Imaging: No visible brain damage
S/S: wide range of physical problems &/or impaired cognition; dazed, disoriented, memory loss, dizziness, HA, behavioral changes; usually resolve within 72 hours

A

Mild! (Concussion)

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11
Q

Mild, Moderate, or Severe TBI?
GCS: 9-12
Loss of consciousness: + >30 min to 6 hrs
Imaging: +/- Visible brain damage, either focal or diffuse
S/S: +/- acute amnesia ≦24 hrs; may require hospital monitoring

A

Moderate!

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12
Q

All TBI pts are as though they have a _____ ___ injury until proven otherwise.

A

Spinal cord injury (transport w/ cervical collar + spine board; spinal precautions)

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13
Q

REVIEW
Spinal Precautions

A
  1. Bedrest
  2. No neck flexion w/ pillow or roll
  3. No thoracic or lumbar flexion
  4. Cervical collar
  5. Log roll for repositioning
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14
Q

Subtle changes in these 3 things can help to determine neurologic deterioration

A

Subtle changes in:
1. BP
2. Consciousness
3. Pupillary reaction to light

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15
Q

The MOST IMPORTANT variable to assess with any TBI is ___ because this is typically the FIRST sign of neurologic deterioration.

A

LOC!
(decrease in arousal, increased sleepiness, restlessness, or combativeness)

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16
Q

EARLY indicators of a change in LOC include (2)

A

Behavioral changes (restlessness, irritability)
Disorientation

17
Q

A change of __ points r/t GCS is considered clinically significant, and the provider should be notified.

A

2 points

18
Q

S/S of Autoregulation impairment

A
  1. Hypotension (or HTN per book)
  2. Decreased pulses
  3. Dysrhythmias
19
Q

Interventions for a TBI (5)

A
  1. ICP monitoring/reduction
  2. IV fluids
  3. BP Mx
  4. O2
  5. Seizure prevention
  6. Intubation/ventilation if necessary
20
Q

What is Cushing Triad and what is it a classic but very late sign of?

A

A classic but late sign of increased ICP!
(Harrell said herniation…)
1. Changes in respirations (pattern)
2. Widened pulse pressure (HTN)
3. Bradycardia

21
Q

Treatment for Cerebral Edema

A

Mannitol (osmotic diuretic)

22
Q

Interventions r/t Mannitol

A
  1. Filtered tubing
  2. Assess for weakness + edema
  3. labs: RFP, osmo, electrolytes
23
Q

Treatment for Diabetes Insipitus

A
  1. IV fluids (maintain hydration)
  2. Meds (Vasopressin)
24
Q

Treatment for Syndrome of Inappropriate Antidiuretic Hormone (SIAH)

A
  1. Hypertonic saline
25
Q

Interventions r/t Nutrition

A
  1. Swallow eval
  2. Parenteral feeding
26
Q

What. the heck is a “Burr hole”

A

ICP monitoring (surgical intervention)

27
Q

Interventions for a Decompressive Craniectomy

A
  1. Strict positioning orders
  2. Helmet when OOB
28
Q

6 Indicators of a poor prognosis r/t a TBI

A
  1. Hypoxia
  2. Fever
  3. Blown or fixed pupils
  4. CPP <70
  5. 2-point change in GCS
  6. Cushing Triad

nsg 410 ms ii (mcp) (34 decks)

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