Chapter 63: Management of Patients with Neurologic Trauma

epidural hematoma signs

Altered LOC, dilated and sluggish non reactive pupil on the side of herniation, hemiparesis or hemiplegia on opposite side of injury.

resp irregular, slow bounding pulse, widened pulse pressure

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply.

TBI temp

Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia.

Cerebral Perfusion Pressure (CPP) 50-70

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

powder under liner

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

temp increase

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

burr hole

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? (considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.)

bruising of mastoid

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?

initial damage to brain

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? (The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.)

basilar skull fracture

Usually occurs following diffuse impact to the head (such as in falls, motor vehicle crashes); generally results from extension of a linear fracture to the base of the skull and can be difficult to diagnose with a radiograph (x-ray). Raccoon eyes (periorbital ecchymosis) and Battle's sign (mastoid ecchymosis).

Decerebrate

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

young, alcohol, drugs, male

Which are risk factors for spinal cord injury (SCI)? Select all that apply.

Subdural Hematoma (SDH)

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

absent brainstem reflexes, apnea, coma

Which signs are considered cardinal signs of brain death? Select all that apply.

blanket

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

epidural

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)?

Autonomic dysreflexia

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

autonomic dysreflexia

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

bradycardia, hypertension, bradypnea- cushing's triad

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.

t6

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

battle sign

Bruising behind an ear over the mastoid process that may indicate a skull fracture.

Increased Intracranial Pressure (ICP)

- Early signs and symptoms may be subtle - As pressure increases, signs and symptoms become more pronounced and the level of consciousness (LOC) deteriorates

ICP nursing management

- elevate the head of the bed as prescribed (gravity helps drain fluid) - maintain head/neck in neutral alignment (no twisting or flexing) - give sedation as ordered to prevent agitation - avoid noxious stimuli (scatter procedures so that client does not become overtired).

Decorticate posturing

-"flexor posturing" or "mummy baby" (think Egyptian mummy preservation) -adduction of arms (arms fold to chest); flexion of elbows and wrists the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Autonomic Dysreflexia/Hyperreflexia

-acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. - occurs only after spinal shock has resolved. - S/S= severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. - occurs w pts w cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided - TX= place immediately in a sitting position to lower BP

halo sign

A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF?

vomits

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client *should be reported immediately.

daily weights

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? (weight loss will alert the nurse to possible fluid imbalance early in the process.)

neutral position (no flexing)

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

paresthesia

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

raccoon eyes and battle sign

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

s/s ICP

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? (Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage)

C5

A client with a spinal cord injury has full head and neck control when the injury is at which level?

Absence of reflexes along with flaccid extremities

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

apply stockings prior

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension? (will improve venous return from the legs. An abdominal binder will also encourage venous return. The nurse should allow time for a slow progression from laying to sitting. Vasopressor drugs may be used to treat the profound vasodilation.)

severe tbi (traumatic brain injury)

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

irrigate, remove debris

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

ambulate independently

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? (Patients with spinal cord injuries from S1 to S5 should be able to ambulate independently, without an assistive device.)

Propofol (Diprivan)

A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? (do not affect cerebral blood flow or ICP)

stabilization, early ambulation

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

sitting up

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? (Autonomic dysreflexia, AKA autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided (Bader & Littlejohns, 2010). The patient is placed immediately in a sitting position to lower BP)

edema, ischemia, infection, seizures, hyperthermia

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply.

hypoxemia, worse neuro deficit

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Halo sign

a blood stain surrounded by a yellowish stain; highly suggestive of a cerebrospinal fluid leak

epidural hematoma

a collection of blood in the space between the skull and dura mater

propofol diprivan

sedative of choice for ICP *do not affect cerebral blood flow or ICP ultra-short acting, rapid onset drug with elimination half-life of less than an hour titratable to its desired clinical effect but still provides the opportunity for an accurate neurologic assessment

Decerebrate posturing

posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe. described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing.

diaphoresis

profuse sweating

SCI

spinal cord injury