Ch 14 Head Injury Flashcards Preview

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Flashcards in Ch 14 Head Injury Deck (39):

What are head injuries classified as

Open or closed... They can be mild, moderate, or severe depending on the Glasgow coma scale


What is a open head injury

Penetrating trauma, the skull integrity is compromised


Open head injuries pose a high risk for what



What are skull fractures often accompanied by

Brain injury.... Damage to the brain tissue may be the result of decreased oxygen supply, or the direct impact from the skull fracture, which caused the trauma. The glucose levels in the brain are negatively affected, resulting in alteration in neurological synaptic ability.


What may head injuries be associated with

Hemmorhage ( epidural, subdural, amid intracerebral) or CSF leakage. Any collection of fluid or foreign objects that occupies the space within the skull poses a risk for cerebral edema, cerebral hypoxia, and brain herniation


What should always be suspected when a head injury occurs

A cervical spine injury must be ruled out prior to removing any devices used to stabilize the cervical spine.


What are manifestations of increased intracranial pressure

Severe headache
Deteriorating level of consciousness, restlessness, irritability
Dilated, pin point, or asymmetric pupils, slow to react or non reactive
Alteration in breathing pattern
Deterioration in motor function, abnormal posturing
Cushing reflex( which is a late finding characterized by severe hypertension with a widening pulse pressure and bradycardia
CSF leakage ( fluid will test positive for glucose)


What diagnostic is used to determine a cervical spine injury

Cervical spine films


What is considered the golden window for head injuries

There is a 1 hour golden window for treatment of head injuries. Emergency treatment during this time frame decreases morbidity and mortality rates especially for epidural hematomas


What is the brain dependent on

Oxygen to maintain function and it has little reserve available I'd oxygen is deprived. Brain function begins to diminish after 3 min of oxygen deprivation


What provides the earliest indication of neurological deterioration

Glasgow coma scale


What are 4 methods used to monitor ICP

1. A thin tube inserted into the lateral ventricle ( intraventricular)
2. Use a bolt or screw placed in the subarachnoid area ( subarachnoid)
3. Place a sensor in the epidural space ( epidural)
4. Place a fiber optic transducer tipped catheter into the subdural or subarachnoid space, ventricle or brain tissue.


What is the expected reference range for ICP

10-15 mm Hg


ICP may be increased by what

Hypercarbia which leads to cerebral vasodilation
Endotracheal or oral tracheal suctioning
Coughing, blowing the nose forcefully
Extreme neck or hip flexion/ extension
Maintains the HOB at angles less than 30 degrees
Increasing intra abdominal pressure ( restrictive clothing, valsalva maneuver)


What are actions that can decrease ICP

Elevate HOB 30 degrees to reduce ICP and promote venous draining
Avoid extreme flexion, extension, or rotation of the head, maintain the body in a midline neutral position.
Hyperventilate clients on mechanical ventilation to keep PaCO2
between 35-38 mm Hg to reduce cerebral blood flow
Monitor fluid and electrolytes and osmolarity to detect changes in Na regulation, the onset of diabetes insipidus, or severe hypovolemia


What is the last sense affected by a head injury



What can secondary brain injury result from

Hypotension, hypoxia, hyperglycemia, hypoglycemia, acidosis, hypercapnia..... MONITOR VITAL SIGNS, BLOOD GLUCOSE, O2 SATURATION, AND ABGs.


What is mannitol

An osmotic diuretic used to treat cerebral edema
Administer IV to treat acute cerebral edema
Insert in dwelling catheter to monitor fluid and renal status. Monitor urine osmality daily
Monitor serum electrolytes and osmality Q 6 HR.


Pentobarbital is used for what

Is used to induce a barbiturate coma to decrease cerebral metabolic demands


When Is pentobarbital initiated

Treatment is performed when the ICP is refractory to treatment and has exceeded 25 mm Hg for 30 min, 30 mm Hg for 15 min or 40 mm Hg for 1 min


What is a barbiturate coma and what is it used for

A barbiturate coma is a treatment of last resort and aims to decrease elevated ICP by inducing vasoconstriction and decreasing cerebral metabolic demands


What are nursing considerations for pentobarbital

Medication is administered in bursts to decrease cerebral activity. Treatment continues until the ICP remains below 20 door 48 hours.
Medication is then slowly withdrawn


What is phenytoin

Is used prophylactically to prevent or treat seizures


Opioid use coupled with hypotension may cause what

Increased ICP


What is a craniotomy

The removal of non viable brain tissue that allows for expansion and or removal of epidural or subdural hematomas. It involves drilling a burr hole or creating a bone flap to permit access to the affected area.


Treatment of intracranial hemmorhages involves what

Surgical evacuation


For supratentorial surgery how MUST the HOB be maintained

At least 30 degrees with body positioning to prevent increased ICP


For a infratentorial craniotomy, how should the HOB be placed

KEEP THE CLIENT FLAT AND ON EITHER SIDE FOR 24-48 hour to prevent pressure on neck incision site. Monitor and maintain wound drain, documenting output Q 8 HR. Monitor wound dressing and mark drainage Q 1-2 hour


What are nursing actions for the mechanically ventilated following a craniotomy

Hyperventilate for 24-48 hours as prescribed to maintain PaCo2 around 35 mm Hg


What are complications of a craniotomy

Brain herniation


What is a brain herniation

The downward shift of brain tissue due to cerebral edema. This can result from brain tissue moving downward through the foramen magnum.


What are clinical findings of a brain herniation

Fixed dilated pupils
Deteriorating level of consciousness
Cheyne stokes respirations
Hemodynamics instability
Abnormal posturing


A intracranial hemmorhage is treated how

With osmotic diuretics


What is treatment for a subdural and epidural hematoma



For a hematoma and intracranial hemmorhage what must the nurse monitor for

Severe headache
Rapid decline in level of consciousness
Worsening neurological function and herniation and changes in ICP


What is neurogenic pulmonary edema

A life threatening emergency. Immediate aggressive treatment is used. Survival is rare.
Findings mimic acute pulmonary edema without cardiac involvement


What is cerebral salt washing ( CSW)

Is causes decreased serum osmolality and hyponatremia. CSW is the primary cause of hyponatremia following neurosurgery. CSW causes hypovolemia, compared with increased extracellular fluid in clients with SIADH.


What is CSW caused by

It is caused by the effects of atrial natriuretic factor ( ANF) located in the hypothalamus. Increase ANF production decreases Na retention in the kidneys. ANF may also prevent renin and aldosterone release.


What are nursing interventions for CSW

Monitor serum electrolytes and osmality daily
Document strict I&O
Weigh daily
Treat electrolyte and fluid imbalance as prescribed
Monitor for dehydration or fluid overload during treatment.