Flashcards in Ch. 14: Head Injury Deck (43):
An injury to the brain that alters the way the brain functions
Bruising of the cerebral tissue
Tearing of the cerebral tissue
How can fractures be?
Loss of consciousness--what is significant about this?
The length of time the client is unconscious
What are signs of minor head injuries?
-Possible loss of consciousness
Signs of severe injury?
Sings if increased ICP in infants?
-Separation of cranial sutures
-High pitched cry
-Setting sun sign
Signs of increased ICP in children?
-Inability to follow simple commands
What are late signs of increased ICP?
-Alterations in pupillary response
-Decorticate or decerebate positioning
-Decreased motor and sensory response
Demonstrates the arms, wrists, and fingers flexed and bent inward not the chest and the legs extended and adducted
Demonstrates a backward arching of the head and arms with legs rigidly extended and toes pointing downward
Dysfunction at the midbrain
Dysfunction of the cerebral cortex
What is the expected reference range of ICP?
Why would a cervical spine x-ray be done for a head injury?
To rule out cervical spine injury
Nursing care: Why do we ensure spine is stabilized?
This is done until spinal cord injury is ruled out
For head injury, we need to maintain patent airway. We also administer oxygen as indicated to maintain an oxygen sat. level greater than ____
Where would we assess for clear fluid drainage. What happens if we find it?
Ears or nose (clear fluid=CSF)
Report to provider!!
What are some actions that would decrease ICP (5)?
1. HOB elevated to 30 degress (promotes venous drainage)
2. Maintain head in midline neutral postiion (avoid extreme flexion, extension, and rotation)
3. Keep body in alignment (avoid hip flexion/extension)
4. Minimize suctioning
5. Tell client to avoid coughing or blowing nose--these can increase ICP
Why would we administer a stool softener for a head injury?
To prevent straining (Valsalva maneuver)
Seizure precautions with head injuries?
What meds are used to decrease cerebral edema?
Corticosteroids (dexamethasone and methylprednisolone)
What mesa are used to treat cerebral edema?
Mannitol (osmotic diuretic)
What meds are used to prevent or treat seizures?
What meds are used in cases of CSF leakage, lacerations, or penetrating injuries?
What meds are used for headache/pain management?
Analgesics like acetaminophen
Talk about surgical intervention of craniotomy.
Involves removal of part of skull
Bone is replaced once edema has resolved
What are 4 complications of head injury?
1. Epidural hemmorrhage
2. Subdural hemorrhage
3. Cerebral edema
4. Brain herniation
What complication: bleeding between the dura and skull
What are clinical manifestations of epidural hemorrhage?
Short period of unconsciousness followed by a normal period leading to herniation, coma, and death
What complication: bleeding between the dura and the arachnoid membrane
What can a subdural hemorrhage be a result of?
Clinical manifestation of subdural hemorrhage?
When would cerebral edema develop?
24-72 hours post op
What are clinical manifestations of cerebral edema?
What complication: Downward shift of brain tissue
What are clinical manifestation of brain herniation?
Loss of blinking
Loss of gag reflex
Pupils dont react to light
A nurse is caring for a child who was admitted to ED after a MVA. The child is unresponsive, spontaneous respirations 22/min, and has laceration on forehead that is bleeding. What is priority intervention at this time?
A. Keep neck stabilized
B. Insert NG tube
C. Obtain VS
D. Establish IV
A nurse is caring for an adolescent who has sustained a closed head injury. Which of the following are clinical manifestations of increased ICP. (SATA)
A. Report of headache
B. Alteration in pupillary response
C. Increased motor response
D. Increased sleeping
E. Increased sensory response
A, B, D
A nurse is caring for a child who has increased ICP. Which of the following are appropriate actions by the nurse? (SATA)
A. Suction the endotracheal tube q2h
B. Maintain quiet environment
C. Use 2 pillows to elevate the head
D. Administer a stool softener
E. Maintain body alignment
B, D, E
A nurse is assessing a child who has a concussion. Which of the following are clinical manifestations of a minor head injury. (SATA)
B. Delayed pupillary response
A, C, D, E