Ch 63 PrepU: Management Neurologic Trauma

Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

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.

The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

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

Autonomic dysreflexia Characteristics of this acute emergency are as follows: Severe hypertension; Slow heart rate; Pounding headache; Nausea; Blurred vision; Flushed skin; Sweating; Goosebumps (erection of pilomotor muscles in the skin); Nasal stuffiness; and Anxiety. The symptoms in the scenario are not symptoms or concussion, spinal shock, or contusion.

The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of?

Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury related to neurologic deficit as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. Disturbed sensory perception (visual) related to neurologic trauma, Feeding self-care deficit related to neurologic trauma, and Impaired verbal communication related to confusion are pertinent but don't take precedence over client safety.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

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

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

When a client reports numbness and tingling in an area, the client is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.

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?

Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

When the cause is removed and the symptoms abate, the blood pressure goes down. The antihypertensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?

The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. 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.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without spinal cord injury (SCI). It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. The first action to take is to place the client in a seated position to lower the blood pressure. Next, the bladder can be assessed for distention, the skin assessed for areas of pressure, and the rectum assessed for a fecal mass, which can all be the reasons for the onset of the symptoms.

A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first?

At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.

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

Clients are at high risk for the development of contractures as a result of disuse syndrome due to the musculoskeletal system changes brought about by the loss of motor and sensory functions below the level of injury. Range-of-motion exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises to prevent footdrop. Range-of-motion exercises are not done to stabilize total body functioning or restore skeletal integrity. Exercise programs are used to prepare to function in the absence of leg function.

A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make?

During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

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

In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Glasgow Coma Scale of 6 The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.

A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except:

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. When the client isn't sedated, he may make attempts to remove the ET tube without realizing what he's doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status.

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:

Irrigates the wound to remove debris Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.

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?

Patients with spinal cord injuries from S1 to S5 should be able to ambulate independently, without an assistive device.

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require?

It allows for stabilization of the cervical spine along with 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?

place the patient in a sitting position Autonomic dysreflexia, also known as 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 blood pressure.

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?

"Neurologic level" refers to the lowest level at which sensory and motor functions are normal. It is not the level of spinal cord transection, the best possible level of recovery, or the highest level at which sensory and motor function is normal.

Neurological level of spinal cord injury refers to which of the following?

The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated (unless basilar skull fracture or facial trauma is suspected), or a tracheostomy may be performed. Until the ability of the patient to breathe on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation and ventilation.

The most important nursing priority of treatment for a patient with an altered LOC is to:

The GCS is a tool for assessing a client's response to stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed "least" responsive.

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as

A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

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)?

"I can apply powder under the liner to help with sweating." Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

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?

spinal shock Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?

Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. An enema and digital stimulation will not relieve a paralytic ileus. Bowel surgery is not necessary.

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?

Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

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. The other clinical findings are within normal limits.

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?

Making nursing assessments Setting priorities for nursing interventions Anticipating needs and complications Initiating rehabilitation

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply.

Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.

The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

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.

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?

With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?

This client has had a prior head trauma with a negative imaging scan. Prior head trauma can lead to the development of a chronic subdural hematoma, which presents with symptoms such as severe headache, mental deterioration, focal neurologic changes, personality changes, and/or symptoms that the client is having a stroke. There is no indication that the client had follow-up imaging based on the prior head trauma, which should be included in protocol management of head injuries. Prior head trauma can lead to the development of a chronic subdural hematoma. Based on the clinical presentation of a severe headache, this is the most likely clinical diagnosis. Based on the clinical presentation, follow-up imaging is indicated to confirm the presence of a chronic subdural hematoma, which can occur following a recent head trauma. Because the head trauma occurred a few months ago, an acute finding would have presented earlier, at the time of injury. The differential diagnosis of chronic subdural hematoma includes a stroke but there is insufficient clinical evidence to support this finding. An electrocardiogram (ECG) is not indicated at this time because there is no provided clinical evidence of any

The office nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results. Complete the following sentence by choosing from the lists of options. The nurse anticipates that the client has developed

Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid). Naloxone, nitroglycerin, and atracurium aren't used to prevent adverse effects of steroids. Naloxone, an endogenous opioid antagonist, has been studied in animals for its action in inhibiting release of endogenous opioids after spinal cord injury. (Endogenous opioids are thought to contribute to secondary damage to spinal cord tissue by reducing microcirculatory blood flow.) Nitroglycerin is used to dilate the coronary arteries. Atracurium is a nondepolarizing muscle relaxant.

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order:

It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The 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. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

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?

A score between 3 and 8 is generally accepted as indicating a severe head injury.

Which Glasgow Coma Scale score is indicative of a severe head injury?

severe hypertension, slow heart rate, pounding headache, sweating Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.

Which are characteristics of autonomic dysreflexia?

young age, alcohol use, drug abuse

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

A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

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

Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Monitoring the patency of an indwelling urinary catheter A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

respiratory arrest and spinal shock Respiratory arrest and spinal shock are the immediate complications of spinal cord injury. Tetraplegia is paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury.

Which of the following are the immediate complications of spinal cord injury?

Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

Symptoms of the epidural hematoma are caused by the expanding hematoma. Usually a momentary loss of consciousness occurs at the time of injury, followed by an interval of apparent recovery (lucid interval). Subdural hematoma is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid.

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)?

grade 3 There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related (Ruff, Iverson, Barth, et al., 2009). A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes (Ruff et al., 2009).

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?