Term
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Definition
GCS based on 3 criteria of eye opening, verbal responses and motor response to verbal command or painful stimuli
Monitor very frequently during acute phase
It does not take the place of in-depth neuro assessment
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Term
| head injury classifications |
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Definition
•Open or penetrating trauma
•High risk of infection
•Closed or blunt trauma
•Mild moderate severe depending on GCS and length period of unconsciousness
•Hemorrhage needs to be treated immed
•Associated with hemorrhage (epidural, subdural or intracerebral) and presence of CSF leakage
•Could lead to cerebral edema cerebral hypoxia, and brain herniation
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Term
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Definition
•Wear helmets when Skateboarding and other risk related sports
•Seatbelts
• Avoid dangerous activities (speeding etoh drugs when driving)
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Term
| assess risk factors for tbi |
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Definition
•Males < 25
•Ages 65-75 (2nd highest incidence)
•Drug, ETOH
•Sports injuries
•Assault
•Gunshot wounds
•Falls
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Term
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Definition
•History from family patient
•When? How? What direction was the force applied?
•Hx of amnesia or unconsciousness-assoc w/ temporal lobe injury
•Examine
•LOC with GCS
•Response to tactile stimuli if unconscious
•Pupillary response to light, corneal and gag reflex,
•Motor function
•Labs-need a tox screen
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Term
| subjective/objective data of TBI nursing care |
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Definition
•Presence of ETOH/Drugs at time of injury
•Amnesia
•LOC document length of time
•Labs
•ABG’s
•ETOH and tox screen
•CBC/diff-to know if they’re hemorrhaging
• BUN –baseline to determine status prior to contrast studies
•Diagnostics
•C-Spine films
•CT (skull, spine etc) MRI –soft tissue
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Term
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Definition
•Severe headache
•Deteriorating LOC, restlessness, irritability
•Dilated, pinpoint, or assymetric pupils, slow to react or non-reactive
•Alterations in breathing
•Cheyne-Stokes, central neurogenic hyperventilation, apnea)
••Deterioration in motor function, abnormal posturing
•Decerebrate, decorticate, flaccid
Cushing’s reflex: late finding of severe hypertension wide pulse pressure and bradycardia
CSF leakage “halo sign”
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Term
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Definition
see diaphoresis in these patients, arrhythmic pattern with long periods of apnea
Cheyne stokes an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.[1] It is an oscillation of ventilation between apnea and hyperpnea with a crescendo-diminuendo pattern, and is associated with changing serum partial pressures of oxygen and carbon dioxide.[2] – usually indicates bleeding
Neurogenic hyperventilation- hemorrhaging on brainstem affecting lower brainstem and eventually breathing will stop
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Term
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Definition
use paper towel and see yellow stain surrounded by blood, fluid tests positive for glucose, otorrhea, discharge from nose
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Term
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Definition
mummy baby
Not functioning much above the level of the brainstem- not a good sign
Brain stem= HR, BP, respiration control
get 3 on GCS in motor section due to flexion of muscles as a neuro muscular response to trauma |
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Term
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Definition
posturing is also called decerebrate response, decerebrate rigidity, or extensor posturing. It describes the involuntary extension of the upper extremities in response to external stimuli. In decerebrate posturing, the head is arched back, the arms are extended by the sides, and the legs are extended.[6] A hallmark of decerebrate posturing is extended elbows.[13] The arms and legs are extended and rotated internally.[14] The patient is rigid, with the teeth clenched.[14] The signs can be on just one side of the body or on both sides, and it may be just in the arms and may be intermittent.[14]
A person displaying decerebrate posturing in response to pain gets a score of two in the motor section of the Glasgow Coma Scale (for adults) and the Pediatric Glasgow Coma Scale (for infants), due to his or her muscles extending because of the neuro-muscular response to the trauma.
After this profound of an injury- just barely operating, low/no likelihood of coming back
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Term
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Definition
•There is a 1 hr golden window
•Educate family to touch and talk with client, assist with care as appropriate
•GCS is earliest indication of deterioration
Treatment for head injuries must be rapid– especially for subdural hematoma
Don’t forget to pay attention to skin– prevent decubiti
Lack of 02 to Brain has 3 minutestill damage begins
Prone to aggressive behaviors, inappropriate emotions, etc
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Term
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Definition
Treatment for head injuries must be rapid– especially for subdural hematoma
Don’t forget to pay attention to skin– prevent decubiti
Lack of 02 to Brain has 3 minutestill damage begins
Prone to aggressive behaviors, inappropriate emotions, etc
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Term
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Definition
•Findings of infection
•Nuchal rigidity (meningitis)
•Bilateral sensory and motor responses
•Implement actions to decrease ICP
•Elevate head 30degrees
•Midline neutral head and body
•Maintain patent airway
•O2 to sat at 90%
•ICP monitor reference range 10-15 mm/hg
•Increased by hypercarbia leading to vasodilitation
•Suctioning, coughing, blowing nose, valsalva
Brudzinski’s sign– check for nuchal rigidity/ meningitis
Elevate to promote venous drainage and reduce ICP
Keep body neutral trunk midline
•Hyperventilate with mechanical ventilation to keep PCAo2 between 35-38 mm/hg
•Provide calm restful environment
•Implement complications
•Turn q2 hr footboard and splints
•Specialty beds
••Monitor fluid and electroytes and osmolarity to detect sodium regulation (diabetes insipidus or SIADH and water (CSW)
•Monitor fluids to ensure that there is no excess of fluid that could increase ICP
•Weigh patient strict I and O
•Safety and seizure precautions
•Hearing is last sense affected
DI,neurological form, called central DI (CDI), which involves a deficiency of argininevasopressin (AVP), also known as antidiuretic hormone (ADH).
SIADH syndrome of inappropriate adh
CSW caused by effects of Atrial natiuretic factor located in hypothalamus, can lead to hyponatremia and decreased serum osmolality and hypovolemia compared with increased extracellular fluids found in clients with SIADH
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Term
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Definition
•Injury to scalp skull or brain
•1.7 million brain injuries per year in US
•52,000 deaths
•275,000 hospitalized
•90,000 long term disabilities
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Term
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Definition
mild concusion
TBI-caused by direct blow to head accel and decend injury (MVA)
coma
death |
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Term
| best approach to TBI is.. |
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Definition
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Term
| common causes and most likely afflicted by |
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Definition
•Falls (35.2%)
•MVA (17.3%)
•Object (16.5%)
•Assault (10%)
•Children 0-4
•Adolescents 15-19
•Adults >65
•Males >Females
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Term
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Definition
contussion
laceration
torn blood vessels and neural tissue |
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Term
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Definition
| inadequate delivery of nutrients and oxygen to the cell |
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Term
| if pressure increases enough |
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Definition
it causes deplacement of brain through or against the rigid structures of the skull
dec in edema and bleeding |
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Term
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Definition
brain suffers traumatic injury
brain swelling inc ICV access
rigid cranium allows no room for expansion so ICP increases
pressure on blood vessels within the brain cause blood flow to slow
cerebral hypoxia and ischemia occur |
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Term
| intracranial pressure pathway |
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Definition
ICP increases
brain may herniate
cerebral blood flow ceases |
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Term
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Definition
•Linear
•Break in continuity
•Comminuted
•splintered
•Depressed
• skull bones Forcefully displaced downward
•Basilar
•Base of skull
•Open
•Dura is open
•Closed
•Dura is closed
Assessed with CT
associated brain injury assessed with MRI
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Term
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Definition
| also mastoid ecchymosis, is an indication of fracture of middle cranial fossa of the skull, and may suggest underlying brain trauma. Battle's sign consists of bruising over the mastoid process, as a result of extravasation of blood along the path of the posterior auricular artery. |
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Term
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Definition
These fractures tend to occur from the tend to travers the paranasal sinuses of the frontal bone or middle ear located in the temporal bone producing hemmhorage from nose, ear, pharynx, and subconjunctiva areas.
Can get facial ecchymosis- Battle’s sign- bruising behind the ear (Mastoid)- blow to temporal region
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Term
| nursing assessment of skull fracture |
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Definition
•Check for Battle’s sign
•CSF otorrhea
•CSF rhinorrhea
•Very serious symptoms
•Risk of meningeal infection via breach of the dural tissue where organisms gain access to CSF/ neural tissues
When trauma creates a shift in these components and other components can’t accommodate, the brain shifts from the cranial vault and herniates
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Term
| gerontologic considerations of brain injury |
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Definition
•Higher morbidity mortality with these injuries
•61% of TBI’S occur with falls in older adults
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•Risk for hematomas because
•Brain weight decreases
Dura becomes more adherent to skull
Reaction time slows with decreasing age
Use of Anticoagulant therapy, ASA
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Term
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Definition
•2 million people per year seek treatment for TBI
•3rd Top reason for trauma death
•3.5-5.3 million people live with the cognitive, physiological and physical consequences, costing ^76 billion per year
•No clear treatment
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Term
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Definition
•(Mild TBI)
•Temporary loss of neurologic function with or without brief LOC
Causes:
•Blunt force from accelerating decelerating force, blow or blast
3 Grades of Concussion
Grade 1
Grade 2
Grade 3
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Term
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Definition
•Grade 1
• transient confusion, no LOC (loss of consciousness), and duration of mental status alterations resolved in less than 15 minutes
•Grade 2
•Transient confusion, no LOC, but mental status sx’s last for longer than 15 minutes
•Grade 3
•Any LOC lasting from seconds to minutes
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Term
| nursing management of mild TBI |
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Definition
•Often overlooked
•Nurse must do careful history and exam
•Monitor for observing for decrease LOC, worsening headache, dizziness, abnormal pupils, vomiting, behavioral changes, irritability, slurred speech, numbness and weakness
Diagnostic studies may be neg
Tranientammnesia indicates Temporal lobe involvement
Frontal lobe damage indicated by irrational behavior
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Term
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Definition
•Brain is bruised
•Moderate to severe head injury
•LOC stupor and confusion
•Peak damage 24-36 hr due to hemorrhage and edema
•Temporal lobe contusions associated with herniaton
•Disruption of RAS fibers affecting arousal
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Term
•Diffuse axonal injury (DAI)
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Definition
•Shearing and rotational forces
•Prolonged traumatic coma
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Term
| planning and goals for brain injury |
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Definition
•Maintain body temp WNL
•Setting priority nursing diagnoses
•Adequate nutritional status
•Maintenance of skin integrity
•Improve coping
•Reduce sleep deprivation
•Effective family coping
•Reduce risk of post traumatic seizures
•Start rehab, increase knowledge of rehab processes (right at bedside)
Know skin is important, oral care is important
Nutrition- altered because they may be on TPN or tube feeds
ABCs- Breathing is super important (duh)
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Term
| preventing further injury as a person comes out of a coma |
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Definition
•Assess for adequate O2 sat
•Assess for bladder distention
•Padded side rails and mitts, no restraints
•Avoid opioids
•Skin care
•Environment stability, reduce risk for visual hallucinations
Opioids depress resps, restrict pupillary response and alters responses
Minimize sleep wake disruption
Lubricate skin
Assess for bladder distention- could be retaining
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Term
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Definition
•Intracranial hemorrhage
•Treated with osmotic diuretics
•Epidural Hematoma
•Surgery required
•Subdural hematoma
•Surgery required
•Monitor for severe headaches rapid decline in LOC, worsening neurologic status
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Term
A nurse is caring for a client post evacuation of subdural hematoma. Which is a priority assessment?
1.Glasgow coma scale
2.Cranial nerve function
3.O2 Saturation
4.Pupillary response
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Definition
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Term
A Nurse is caring fro a client immediately following a MVA. Client is unresponsive, spontaneous resp of 22/min and a bleeding laceration to the skull.
Which is the priority nursing action at this time?
1.The nurse keeps neck stabilized
2.Insert NG tube
3.Monitor BP and Pulse
4.Establish IV and start fluids
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Definition
| 1, nurse keeps neck stabilized |
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Term
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Definition
•200,000 persons in US afflicted
•15-40 new cases per million people per day
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Term
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Definition
•Loss of motor function
•Loss of sensory function
•Loss of reflex function
•Loss of control of elimination
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Term
| levels of quadripeliga and parapeligia in spinal cord injury |
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Definition
•Cervical
•Quadraplegia
•Paralysis/paresis of all four extremities and trunk
•Above C4 risk for impaired spontaneous ventilation
•Below T1
•Paraplegia
•Paralysis/paresis of lower extremities and truncal instability, bowel bladder
•
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Term
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Definition
transient concussion
contusion
laceration
compression
transection
A pt fully recovers from transient concussion
Transection- most devastating
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Term
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Definition
primary injuries
secondary injuries-nerve reaction where tissue swells and degenerates
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Term
| nursing considerations post SCI |
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Definition
•Prevention of further damage to spinal cord
•Respiratory compromise with C4 and above injury
•Orthostatic hypotension
•Neurogenic shock
•Manage Autonomic dysreflexia (BP, HR, temp regulation, CO)
•Education of patient and family
•NG tube in for decompression
•Need Folley
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Term
| nursing management of autonomic dysreflexia |
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Definition
•Sit client up and notify provider
•Troubleshoot/treat reason: could be distended bladder, UTI, calculi- cold stress, draft, fecal impaction, clothing, irritations, etc.
Can happen at any time in life of patient with SCI
*First thing you do is sit them up* - less of pressure in brain, more drainage- can resolve the symptoms
BP goes up
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Term
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Definition
•Sudden depression of reflex activity
•Spinal cord levels below injury are without sensation paralyzed and flaccid and the reflexes are absent.
Need to be monitoring for neurogenic issues if someone has an injury to c-spine
•Caused by loss of autonomic nervous system fucntion below level of lesion
•Vital organs affected
•Decreases in
• BP. Cardiac output. Venous pooling in the extremities.
•Peripheral vasodilation. Lack of perspiration in paralyzed areas due to black of sympathetic activity.
•Sudden high temps due to sympathetic dysegulation
•In cervical and spinal cord injuries, innervation to accessory muscles causes decreased vital capacity, retention of secretions, respiratory failure and decrease O2 levels pulmonary edema
•VTE
•Prophylactic indwelling filters
•Reflexes that initiate bowel and bladder are affected
•Catheterize
•Bowel distension
•Paralytic ileus first 3-7 days
•NG for intestinal decompression
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Term
american spinal injury association impairment scale-don't have to know all details
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Definition
•A: complete. No sensory or motor function is preserved in the sacral segments S4-S5.
B: sensory incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5 (light touch, pin prick at S4-S5 or deep anal pressure), AND no motor function is preserved more than three levels below the motor level on either side of the body.
C: motor incomplete. Motor function is preserved below the neurological level and more than half of key muscle functions below the single neurological level of injury (NLI) have a muscle grade less than 3.
D: motor incomplete. Motor function is preserved below the neurological level and at least half of key muscle functions below the NLI have a muscle grade of 3 or greater.
E: normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.
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Term
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Definition
•Bundle of nerve roots emanating from L1-2 area
•Looks like horses tail
•The most common cause is lumbar intervertebral disk herniation. Other causes include traumatic injury, abscess, spinal anesthesia, tumor ankylosing spondylitis, inferior vena cava thrombosis, lymphoma, and sarcoidosis. The nerve roots of the caudaequina are susceptible to injury and increased permeability, which may then lead to edema formation even with the slightest injury.
Numbness in perineal area- loss of sexual sensation, urinary retention, can be very painful and disabling
Anything that compresses caudaequina nerve roots can cause it
CES is rare, occurs equally in men and women, and isn't age specific. Occurring traumatically or atraumatically, CES may result from any lesion that compresses the cauda equina nerve roots, which can occur from inflammation, direct compression, ischemia, or venous congestion. CES has no definite criteria for diagnosis. Diagnosis includes your patient's clinical history, physical exam, and radiologic testing. as
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Term
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Definition
•The patient usually presents with low back pain that's different than common lumbar strain, unilateral or bilateral lower extremity motor or sensory abnormality, b/b complaints.
•Bladder sxs: incontinence or retention, bowel incontinence, perineal anesthesia, pain in the legs or radiation to the legs, reflex abnormalities (loss or diminished), pain localized to the low back, and poor sphincter tone.
•To prevent and avoid lifelong disability, a careful examination and history taking is crucialfor referral to spine specialist
if caught early and diag correctly, long term projects can be prevented
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Term
Nurse is planning care for a person with fresh T12 fracture and incomplete SCI. Person has no control of lower limbs bowel or bladder. Which is the nurses highest priority?
1.Prevention of further damage to spinal cord
2.Prevention of contractures of lower extremities
3.Prevention of skin breakdown of areas that lack sensation
4.Prevention of postural hypotension when moving patient
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Definition
| prevention of further damage to spinal cord |
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