Acute Cranial Problems

Question 1

Head injury

Answer 1

refers to any trauma to scalp, skull, or brain

Question 2

Head trauma

Answer 2

refers mainly to cranio-cerebral trauma, which includes alteration in consciousness, regardless of the duration.
Head trauma has high likelihood for poor outcome.

Question 3

What are time periods of death from head trauma?

Answer 3

Immediately after the injury
Within 2 hrs after the injury
Approx. 3 weeks post injury

Majority of death from a head injury occur immediately after the injury

Question 4

Types of head injury

Answer 4

Scalp lacerations
- most common type
- scalp is highly vascular (lots of bleeding)
- complications: blood loss and infection
Skull fractures
- Linear or depressed
- Simple, comminuted (3 or more pieces), or compound
- Closed or open

Question 5

Skull fracture manifestations

Answer 5

Racoon eyes & rhinorrhea (CSF leaking from nose)
Battle sign (postauricular ecchymosis) with otorrhea (CSF from ear) - bruising behind ear
Halo or ring sign (double ring) -Yellowish ring encircles blood if CSF is present

Question 6

What does CSF leak increase the risk of?

Answer 6

Meningitis

Question 7

What are head traumas categorized as?

Answer 7

diffuse (several areas to brain) - concussion
focal (localized) – one area - contusion, hematoma

Question 8

Classification of brain injury

Answer 8

Mild (GCS score 13-15)
Moderate (GCS 9-12)
Severe (GCS 3-8)

Question 9

Concussions

Answer 9

diffuse injury
a sudden transient mechanical head injury with disruption of neural activity and a change in LOC

Question 10

Postconcussion syndrome

Answer 10

seen 2 weeks to 2 months post concussion

Question 11

Chronic traumatic encephalopathy (CTE)

Answer 11

Degeneration in brain from repeated concussions

Question 12

Signs of concussions

Answer 12

Brief disruption in LOC
Amnesia
Headache
Short duration

Question 13

Signs of postconcussion syndrome

Answer 13

Persistent headache
Lethargy
Personality & behavioral changes
↓ short-term memory, ↓ attention span
Changes in intellectual ability

Question 14

Diffuse axonal injury (DAI)

Answer 14

Widespread axonal damage that occurs following mild, moderate, or severe traumatic brain injury (TBI)
Trauma changes the function of axon → results in axon swelling
signs & symptoms: decreased LOC, increased ICP, decorticate, decerebration, global cerebral edema

vegetative state is common

Question 15

Focal injury

Answer 15

Can be mild to severe; localized to an area of injury
Consists of laceration, contusions, hematomas, and cranial nerve injury

Question 16

Laceration

Answer 16

focal injury
tearing of brain tissue
Often associated with penetrating injuries
Severe tissue damage

Question 17

Contusion

Answer 17

focal injury
Bruising of brain tissue within a local area

Coup-contrecoup injury

Question 18

what is Coup-contrecoup injury>

Answer 18

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

Question 19

Complications of head injury

Answer 19

Epidural hematoma
Subdural hematoma
Intraparenchymal hematoma
Traumatic subarachnoid hemorrhage

Question 20

Epidural hematoma

Answer 20

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

Question 21

Subdural hematoma

Answer 21

From bleeding between dura matter & arachnoid layer of brain
Usually venous in origin, thus, slower to develop

Question 22

Types of subdural hematoma

Answer 22

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
- Alcoholics increased risk

Question 23

Intraparenchymal hematoma

Answer 23

aka intracerebral hematoma
Collection of blood within parenchyma, from bleeding within brain tissue itself
Usually occurs in the frontal and temporal lobes

Question 24

Traumatic subarachnoid hemorrhage

Answer 24

Result of traumatic forces damaging the superficial vascular structures in subarachnoid space
May dispose pts to cerebral vasospasm & ↓CBF

Question 25

Functions of the brain

Answer 25

Frontal lobe - behaviour, intelligence, memory, movement Parietal lobe - intelligence, language, reading, sensation Occipital lobe - vision Temporal lobe - behaviour, hearing, memory, speech, vision Cerebellum - balance, coordination Brain stem - blood pressure, breathing, consciousness, HR, swallowing

Question 26

Brain tumors

Answer 26

Primary- arising from tissues in the brain Secondary- resulting from a malignant neoplasm located somewhere else in the body. These are the most common kind. Classified from the tissue they arise from for ex meningiomas. Over half of all brain tumours are malignant. Unless treated all will eventually cause death by tumour volume leading to increased ICP.

Question 27

Manifestations of brain tumors

Answer 27

Depend on location, rate of growth and size. headache common symptom (worse at night). Dull and constant. Seizures especially in gliomas and brain metastases. Nausea and vomiting from increased ICP Cognitive and motor dysfunctions and sensory deficits depending on location of the tumour.

Question 28

What does tx of brain tumors aim to do?

Answer 28

1. Identifying the tumour 2. Removing or decreasing tumour mass. 3. Preventing or managing increased ICP

Question 29

What is the care of brain tumors?

Answer 29

meds - steriods sx - risk of removing part of the brain that is functional (removes tumor) Ventricular shunts (fluid in ventricles- risk of infection and displacement) Radiation Chemo (systemic) and targeted therapy (difficulty d/t BBB)

Question 30

Neurosurgery reasons

Answer 30

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 spine Congenial abnormalities - hydrocephalus Cerebral and spinal tumors - glioma Degenerative disorders - Arthritic changes in the spine

Question 31

Surgical approaches

Answer 31

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 - bone flap is surgical removed and then returned after sx. performed so brain can be accessed for further sx Decompressive craniectomy - bone flap is removed but us not returned to skull after sx. performed to relieve pressure on brain Hypophysectomy - removal of pituitary gland

Question 32

Post craniotomy care

Answer 32

Safe recovery from anesthesia Monitoring for signs of increased ICP & its clinical management Provide nursing care based on pt’s degree of dependency Promote rehabilitation

Question 33

Management of Increased ICP

Answer 33

Hourly neurological observations, e.g., Glasgow Coma Scale VS per protocol, e.g., q1h Full neurological assessment Report any change in pt’s condition immediately Admin ordered meds to increased ICP Likely caused by hemorrhage into wound site, cerebral edema, or hydrocephalus - increase HOB to 30-40 degrees - Chin and sternum should be aligned - Pace nursing activities to  frequency of stimulation - Prevent constipation (don’t want straining) - 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

Question 34

Wound care

Answer 34

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

Question 35

Safety considerations

Answer 35

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

Question 36

Bacterial meningitis

Answer 36

Acute inflammation of meningeal tissues surrounding brain & spinal cord Medical emergency

Question 37

Clinical manifestations of bacterial meningitis

Answer 37

Fever, severe headache N/V Nuchal rigidity (resistance to flexion of the neck) +ve Kernig sign (pain when hip flexed to 90º and extension of the knee)

Question 38

Complications of bacterial meningitis

Answer 38

↑ ICP (major cause of altered mental status)

Question 39

Encephalitis

Answer 39

acute inflammation of brain (from virus)

Question 40

Manifestations of encephalitis

Answer 40

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