Week 4 (MVC) Head injury/ICP Quiz
What is a Basillar fracture?
- Broken bones patient can bleed to death without any signs of blood patient needs to be on C-spine precautions. -
What is CPP?
- CPP (Cerebral pulse pressure) in the brain - It must be maintained within narrow limits because too little pressure could cause brain tissue to become ischemic, and too much could raise intracranial pressure.
What is the main cause for the patient to be in a persistent vegetative state?
- Diffuse Axonal Injury
What interventions should be done for a patient who was in a MVC and suffered a TBI
- Etomidate(sedative agent 0.3mg/kg) and Succinylcholine(paralytic agent 1mg/kg) - Intubation - 18 french tube, taped at 22cm at the teeth - Organic tube placed - CT scan - Plain X-ray portable chest and (portable pelvis) - Warming lights? - Foley catheter placed - Second IV placed - pain meds
How to perform the Glasgow coma scale?
- Eye response: 4- spontaneous (found with their eye open) 3- To verbal stimuli 2- To pain 1- None - Verbal response: 5- Oriented 4- Confused 3- Inappropriate words 2- Incoherent 1- none - Motor response: 6- Obeys commands 5- localizes pain 4- withdrawals from pain 3- Flexion to pain or decorticate (remember to the Cor) 2- Extension to pain or decerebrate ( extension to pain)
Why is it important to provide a thorough and accurate hand off report to the nurse who will be assuming care of a patient?
- For patient safety and continuity of care
What patients should we look out for when taking Mannitol?
- Heart failure pts. - Too rapid of an infusion of large amounts of mannitol will cause a shift of intracellular water into the extracellular compartment resulting in cellular dehydration
What is Cushings Triad?
- Irregular respirations, systolic hypertension with widening pulse pressure and bradycardia (increasing systolic and decreasing diastolic) - all due to an elevated ICP usually these are late signs and maybe irreversible
What is mannitol and why do we give it, how does it work, and why would it be indicated?
- Mannitol is an osmotic diuretic used to treat cerebral edema used for a patient with ICP the medication draws the fluid from the brain into the blood - Sucks water out of the brain and into the vessels (intrasystem) then pee it out.
Should you place an NG tube down on a patient with a brain injury?
- NEVER because it can go in their brain and if they have a basilar fracture that makes it worse
What interventions do we perform for a patient who is unconscious and has a GCS of 6?
- Patient needs 2 IV'S - labs rainbow - cardiac monitor - intubate <8 GCS - All pts. get Tetanus shot coming in from the trauma - Head injury gets oral gastric tube (OG) because trauma patients puke a lot and it helps prevent aspiration - Foley to monitor kidney function - Pain meds - Q5 vital signs - CT Scan (head) to visualize and detect any injuries - Imagining (plain film ) to the pelvis
Upon arrival in the ICU the physician asks a nurse to perform a ventriculostomy to facilitate the monitoring of intracranial pressure What sources can you check to know if this fall within your scope of practice?
- Policy and procedures manuals or state board Florida nurse practice ACT
What are 3 different ways to arouse a patient who is unconscious?
- Pressure point - Sternum rub - Eye push
C spine precautions
- Spine remains neutral every time - Jaw thrust instead of head tilt to open airway to prevent injury - Bed rest/no flexion - use log roll at least 4, people - KEEP SPINE IN CENTER ALL TIMES
What is a FAST exam and what does it tell you?
- The Focused Assessment with Sonography in Trauma (FAST) is an ultrasound protocol developed to assess for hemoperitoneum and hemopericardium. - The exam tells you if there is bleeding in the abdomen
With single motor vehicle crashes what should we always think?
- Think maybe a suicide attempt
What is a traumatic brain injury?
- Traumatic force to the skull and brain can come from
What is the External Ventricular Drain?
- Tube placed in ventricle to drain CSF and relieve pressure on brain due to acute injury, blockage, or infection.
What is the Glasgow coma scale?
- Used to assess depth and duration of impaired consciousness and coma. -Predicts ultimate functional outcome.
What is a ventriculostomy?
- a surgical procedure that involves the placement of a catheter connecting the ventricles of the brain to an external collecting device.
Why are warming lights needed for a patient with a traumatic brain injury?
- because brain injuries cause patients to have a decrease in temperature regulation
What is Emergency severity index (ESI)?
- it is a 5 level system that helps us *triage pts -based on illness & severity, ABCDs, and resource utilization
What may be indicated if a patient's temperature is increasing who has a TBI?
- remember the patient is under a warming light but if the patient has a temperature of 100.4 or >must intervene
What makes a basilar fracture so dangerous?
- the patient can bleed to death due to the bone shift that can puncture the *Carotid artery (which is the major artery that supplies blood to the brain)
What will a patient with ICP look like?
-Severe h/a - N/V - Decrease LOC - restlessness - irritability - Dilated or pinpoint non reactive pupils - Cranial nerve dysfunction - Alterations in breathing (Cheyne stokes - a pattern of -- rapid deep respirations followed by rapid shallow --- respirations, alternating with periods of apnea.) - Abnormal posturing decorticate posturing and decerbeate
How much of Etomidate do you give to sedate a patient?
0.3mg/kg if the patient weighs 155pounds how much etomidate should we give them 21 but doc might just say give 20
What is the worst severity index?
1
Name the 3 componets that muist be balanced for a normal ICP to be maintained?
1. Brain tissue 85% 2. Blood 10% 3. CSF 5%
How much Succinylcholine should you give a patient for paralysis?
1mg/kg so if the patient weighs 155 pounds they will receive 70.5 doc might just say give them 80
You have a Blood pressure of 128/65 and a ICP of 22 what is the CPP?
1st 128+65+65/3 = 86 2nd 86-22 = (64)
What is a normal pulse pressure?
40-60
What is the normal ICP?
5-15 mmHg
What is the normal CPP?
60-100
A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? A. The client rigidly extends his arms. B. The client internally flexes his wrists. C. The client curls into a fetal position. D. The client internally rotates his legs.
A- A client who exhibits a decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a *severe brain stem injury and late neurological decline.
What is decorticate posturing?
Abnormal flexion: Hands pulled to chest (cor) Internal rotation and adduction of the arms with flexion of the elbows, wrists & fingers. "flexor - toward the cord"
Increased intracranial pressure
Anything that causes swelling, bleeding, in the brain will increase this pressure.
A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure? A. Battle's sign B. Periorbital edema C. Dilated pupils D. Halo sign
C- Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately.
The nurse is caring for a client with increased intracranial pressure (ICP). Which assessment finding would have the most priority? A. Tachycardia B. Hypothermia C. Unequal pupil size D. Decreasing blood pressure
C- Pupillary assessment is necessary to detect changes in ICP. Normal assessment for pupils is PERRLA or "Pupils equal, round and reactive to light and accommodation". Pupils should both be round and the same size (between 2-5 mm in diameter). Pupils should also react to light and accommodate appropriately. Tools for this assessment include a penlight, pupil scale, and a pen or the nurse's index finger to check for accommodation. Compression of the third cranial nerve (oculomotor nerve) will result in unequal, fixed, or dilated pupils.
An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions
C- The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death.
A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). This increase in ICP is due to which of the following? A. Decreased cerebral perfusion B. Leakage of cerebral spinal fluid C. Rigid skull containing cranial contents D. Brain herniated into the brainstem
C- The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP.
What should you do if the ICP is greater than >15?
Call the Doc just to make sure may only be concerned if its above 20
What is decerebrate posturing?
Extensor response: Hands pushed to sides and body -- hyper-extended. Arms are stiffly extended, adducted & hyperpronated. Hyperextension of the legs with *plantar flexion of the feet. - ballerina (May indicate more serious damage.) "extensor = All E's"
What can increase ICP?
Hypercarbia, (an increase in carbon dioxide in the bloodstream) which leads to cerebral vasodilation Endotracheal or oral tracheal *suctioning Coughing Extreme neck or hip flexion/extension Maintaining the head of the bed at an angle LESS than 30° Increasing intra‑abdominal pressure (restrictive clothing, Valsalva maneuver)
What kind of fluid do we give to patients with head injuries?
Hypotonic solution 0.45% NS
The nurse caring for a client with a brain injury administered mannitol for increased intracranial pressure. Which is the most important for the nurse to monitor following administration of mannitol?
Intake and Output - Mannitol is a diuretic, the excessive fluid in the brain is eliminated through the kidneys as urinary output. While on mannitol, the urinary output is generally more than the input. The nurse should monitor the client for intake and output. The goal with this therapy is reduction of cerebral edema to restore neurologic function to the client.
What is a trauma flow sheet?
Keeps chart of anything that has been done by the trauma team.
Level 1 ESI?
Level 1: requires immediate life-saving intervention? for ex: cardiac arrest or massive bleeding *(every specialty is in the house)
Level 2 ESI?
Level 2: High-risk situations or patient is confused lethargic or has severe pain and is disoriented for ex: Cardiac related, chest pain, or asthma attack *(non life-threatening at this second) they have every specialty but they are not all in house
Level 3 ESI?
Level 3: (Regional hospital) Stable and need multiple types of resources to dx or tx (such as labs x-ray, imaging) for ex: abd pain, high fever, and cough
Level 4 ESI?
Level 4: (urgent care) Stabe need only 1 type of resource anticipate (such as only an x-ray or only sutures) for example: simple lac or painful urination
Level 5 ESI?
Level 5: (urgent care) stable and no resourced anticipated except oral or topic meds, work notes or prescriptions for Rx: rash, work not, Rx refills
A nurse is caring for a client with increased intracranial pressure (ICP) following a diagnosis of traumatic brain injury. The client is on a ventilator and requires suctioning. Which of the following is a priority when suctioning a client with increased intracranial pressure?
Limit suction to reduce elevations in ICP - The most important nursing interventions with a client with ICP are those that reduce ICP from increasing. Suctioning greatly increases ICP. A sudden increase in pressure can lead to further brain injury, seizure, coma, stroke, or death. If suction is needed, suction passes should be limited and should allow for rest periods between passes, should be hyperventilated, and provide increased oxygen prior to the procedure. cerebral damage when suctioning is utilized.
How do you identify and interpret trends you see in vital signs?
Look for a constant increase or decrease in patient BP,Temp, Pulse or even labs may also have trends are they increasing or decreasing?
How do you calculate CPP?
MAP-ICP for example...
You are carefully monitoring the patient and the ICP monitoring equipment. After repositioning the patient, you will do what to ensure the ICP is being monitored accurately?
Make sure the transducer of the ICP catheter is leveled aka as the (external ventricular drain)
What does a tetanus shot do for a patient?
Makes sure that you have enough antibodies to neutralize the toxins that are produced by Clostridium tetani.
If your patient's CPP elevates to an unsafe level you may receive an order to start an infusion of what medication?
Mannitol
Why dont we give normal saline to patients with head injuries?
Normal saline increases fluid retention which can increase ICP which increases the BP which we do not want ~
Who usually shows up first from the trauma team?
Nurse
How is shock and ICP opposite from each other?
Shock: 1. increase heart rate 2. Decreased blood pressure 3. Increased respiratory rate ICP: 1. decreased heart rate 2. increased BP *think the pressure is rising 3. decreased respiratory rate
What does a decreased heart rate and and oxygen indicate?
Signs of Cushings triad
The nurse is caring for a client with increased intracranial pressure. Which respiratory pattern changes will signal increased intracranial pressure?
Slow, irregular respirations - Respiratory changes associated with increased intracranial pressure are the result of deterioration of neural control of respirations, which is controlled by the brain stem. Deterioration and pressure produce irregular respiratory patterns. There is reduced perfusion to the brain from the swelling.
Medications that end in "tol" usually have what in them?
Sugar
How do you calculate a widened pulse pressure? (WPP)
Systolic - Diastolic for example for a BP of 120/80 120-80 = 40 WPP
True or False sedate before you paralyze?
True
True or false 8 or less GCS intubate
True
True or false GCS of 3 we call life bank?
True
True or false morphine comes in a prefilled syringe of 10
True
True or false oral meds/ topical meds and prescriptions are not considered resources?
True
What is indicated when the patient's systolic BP is increasing and their diastolic is decreasing?
Widened pulse pressure
Even if our CPP is good should we still report a high ICP?
Yes
Can you have an OG tube and ETT at the same time ?
Yes because the OG tube goes in the mouth and the the ETT goes in the trachea
What is Diffuse Axonal Injury?
shearing (tearing) and rotational force produces brain damage
What does every person that comes to the trauma unit?
the patient gets warmed up and a tetanus shot
