Acute Intracranial Conditions Flashcards
Describe different types of head injury
Time periods of death from head trauma:
-Immediately after the injury
-Within 2 hrs after the injury
-Approx. 3 weeks post injury – multi system failure
types of head injury:
Scalp lacerations (most common)
-Scalp is highly vascular _ profuse bleeding.
-Major complications are blood loss and infection.
Skull fractures
-Linear or depressed
-Simple, comminuted, or compound
-Closed or open
Clinical Manifestations:
-basilar skull fracture’s manifestations:
Battle sign - bruising behind ears
-Battle sign (postauricular ecchymosis) with otorrhea
(-Racoon eyes & rhinorrhea- CSF leak from nose)
-Halo or ring sign- Yellowish ring encircles blood if CSF is present
basliar skull fracture: CSF leak from the meninges
CSF leak ↑ risk for meningitis
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Head Trauma:
Brain injuries are categorized as:
-focal (localized) ex contusion, hematoma
-diffuse-Damage to brain cannot be localized ex concussion
FOCAL
Focal injury
-Consists of laceration, contusions, hematomas, and cranial nerve injury
Laceration:
-tearing of brain tissue
-Often associated with penetrating injuries
-Severe tissue damage
Contusion
-Bruising of brain tissue within a local area
-Coup → contusions or lacerations occur both at the site of direct impact of brain on the skull
-contrecoup → at a secondary area of damage on opposite side away from injury, leading to multiple contused areas
Coup-countercoup ex: hit head hard on forehead which whips head back, causing damage to front and back (primary and secondary impact)
DIFFUSE injuries:
Concussion: a sudden transient mechanical head injury with disruption of neural activity and a change in LOC
-Signs of concussion
Brief disruption in LOC
Amnesia
Headache
Short duration
Postconcussion syndrome: seen 2 weeks to 2 months post-concussion
Symptoms
Persistent headache
Lethargy
Personality & behavioral changes
_ short-term memory, _ attention span
Changes in intellectual ability
Chronic traumatic encephalopathy (CTE)
-Degeneration in brain from repeated concussions
Diffuse axonal injury (DAI)
-Widespread axonal damage that occurs following mild, moderate, or severe traumatic brain injury (TBI)
-Trauma changes the function of axon → results in axon swelling
-Clinical signs & symptoms
decrease LOC
increase ICP
Decortication, decerebration
Global cerebral edema
90% of pts with severe DAI remain in persistent vegetative state
Complications of Head Injury
Complications of Head Injury
-Epidural hematoma
-Subdural hematoma
Acute subdural hematoma
Subacute subdural hematoma
Chronic subdural hematoma
-Intraparenchymal hematoma
-Traumatic subarachnoid hemorrhage
Epidural hematoma:
-From bleeding between dura & inner surface of skull
-Often result of torn artery
Symptoms:
unconsciousness at the scene
A brief lucid interval followed by ↓ LOC
Headache, N/V
*Artery bleeds rapidly = neurological EMERGENCY
Subdural hematoma:
-From bleeding between dura matter & arachnoid layer of brain
-Usually venous in origin, thus, slower to develop
-Acute subdural hematoma
signs within 48 hrs of injury
↑ ICP; ↓ LOC, headache
Subacute subdural hematoma
Occur within 2- 14 days of injury
Subdural hematoma may appear to enlarge over time
Chronic subdural hematoma
Develops over weeks or months after a seemingly minor injury
Peak incidence in 50s and 60s
-chronic alcoholics
Classic signs in kids: Vomiting, sick, sleepy. Watch for 24-48 hours. Don’t let them fall sleep. ICP = take to ER
Intraparenchymal hematoma:
aka intracerebral hematoma
Collection of blood within parenchyma, from bleeding within brain tissue itself
In 16% of head injuries
Usually occurs in the __FRONTAL_______and ___TEMPORAL________ lobes
Traumatic subarachnoid hemorrhage:
Result of traumatic forces damaging the superficial vascular structures in subarachnoid space
May dispose pts to cerebral vasospasm & ↓CBF
Vasospasm: brain blood vessels narrow and block blood flow. Fever, stiff neck, paralysis one sided, decreased LOC
Explain the nursing care of patients with head injury.
Explain the types, clinical manifestations and interprofessional care of brain tumours.
Brain Tumours
-Primary- arising from tissues in the brain
-(majority) Secondary- resulting from a malignant neoplasm located somewhere else in the body
Unless treated all will eventually cause death by tumour volume leading to increased ICP, brain will herniate, death.
Clinical Manifestations:
-Depend on location, rate of growth and size.
-(common) headache, worse at night. Trouble sleeping, dull constant pain, occasional throbbing
-__nausea_____ and _vomiting______ from increased ICP
-Seizures especially in gliomas and brain metastases.
Gliomas: glipma cells
Glioglastoma is very aggressive, will die
Interprofessional Care
Identify the tumour
Remove or decrease tumour mass.
Prevent or manage increased ICP
Medication
-common med for brain tumour to decrease swelling: prednisone (steroids), dexamethasone, methylprednisone. Can make you crazy
Sx
-is preferred tx to remove tumour
Ventricular Shunts
-fluid in ventricles so put catheter in to drain fluid.
-Risk of draining too much fluid, too quickly (hypotension shock), infection, misplacement
Radiation
-seeds implanted in brain and slowly release small amounts of radiation. Not systemic. BBB. Only certain meds are effective or brain
Chemotherapy and Targeted Therapy
-systemic tx (affects whole body)
-difficult because of BBB
Describe the nursing management of someone undergoing cranial surgery.
Neurosurgery
-Reasons
-The removal or repair of brain tissue to prevent more harm
-To give palliative relief of distressing symptoms when the cause cannot be removed
Trauma
-Fractured skull
-Traumatic brain injury
Infection
- Cerebral and spinal abscesses
Vascular disorders
-Cerebral aneurysm
-Arteriovenous malformation
Spinal disorders
- Tumors of the spine
Congenial abnormalities
- hydrocephalus
Cerebral & spinal tumors
- glioma
Degenerative disorders
- Arthritic changes in the spine
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Surgical approaches:
Burr Holes:
-Holes drilled into skull and is used for insertion of brain needles to remove tissue for biopsy, or subdural hematoma
-To insert Gigli’s saw to create a bone flap in a craniotomy
Craniotomy
-skull piece removed, returned later
Decompressive craniectomy
-Remove flap and leave off, allowing brain to expand so doesn’t put pressure
Hypophysectomy
-Remove the pituitary gland. Go up the nose. For cancer or if pit gland is overactive
Post craniotomy nursing care
-Principles of care:
Safe recovery from anesthesia
Monitoring for signs of ICP & its clinical management
Provide nursing care based on pt’s degree of dependency
Promote rehabilitation
1) Management of ICP
-neuro vs
Glasgow Coma Scale q1h
hand grips (equal)
pronator drift and close eyes -drop is bad and indicated opposite sides injury)
feet (pedal, toes to nose) bilat,
-if one side is weaker than the other – bleed is the opposite side.
-Pupils are on same side as injury
-VS per protocol, e.g., q1h
-Full neurological assessment
-Report any change in pt’s condition immediately
-Admin ordered meds to decrease ICP
ICP likely caused by hemorrhage into wound site, cerebral edema, or hydrocephalus
-HOB to 30-40 degrees
-Chin and sternum should be aligned
-Pace nursing activities to decrease frequency of stimulation
-Prevent constipation
-Pain control
-Require good oxygen supply and sufficient CO2 to stimulate respiration
-If cerebral edema is causing deterioration of neurological status =May need to administer Mannitol
2) Wound care
-Inspect incision to ensure edges remain well approximated and staples/sutures intact
-Monitor for redness, discharge, signs of infection
-Incision usually left open to air
-Removal of sutures, usually in 2 wks
-Cover incision when going outside
3) Safety considerations
-Support positioning with towels and pillows to prevent pressure on surgical site
-Sign at bedside e.g, “No right bone flap”
-Keep bed at lowest level – risk of falling
Know the Glasgow Coma Scale scores that indicate the level of brain injury.
Classification of brain injury: (GCS score)
Mild 13-15
Moderate 9-12
Severe 3-8
Describe the primary causes and clinical manifestations of bacterial meningitis and encephalitis.
Bacterial meningitis-Acute inflammation of meningeal tissues surrounding brain & spinal cord
-If untreated, mortality rate near 100% =emergency
Leading causal agents:
-Streptococcus pneumoniae
-Neisseria meningitidis
Clinical manifestations:
-Fever, severe headache
-n/v
-Nuchal rigidity (resistance to flexion of the neck)
-positive Kernig sign (pain when hip flexed to 90º and extension of the knee)
Complications
↑ ICP (major cause of altered mental status)
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Encephalitis:
-Acute inflammation of brain
-Usually caused by a virus
Clinical manifestations:
-Onset is typically nonspecific
-Fever, headache, N/V
-Signs appear on day 2 or 3
-Signs may vary from min. to coma
-Hemiparesis
-seizures, tremors,
-cranial nerve palsies
-personality changes
-memory impairment, amnesia
