Head and Brain Injuries
what are the interventions for decreasing ICP?
HOB at least 30 degrees and body alignment avoid extreme flexion, extension, or rotation airway and oxygen stool softeners and avoid valsalva and straining turn slowly provide a calm, restful environment
what are the measures for patients leaking CSF?
HOB elevated loose collection of pad nothing in the nose or ears no sneezing or blowing nose no NG tube because it could go to the brain no nasotracheal suctioning
what is included in the history for brain injury patients?
HPI (mechanism of injury) loss of consciousness home medications
what are the diagnostic tests for brain injuries?
ct scan MRI, PET, evoked potential studies (more details for specific injury) transcranial doppler studies cervical spine x-ray glasgow coma scale
when do deaths occur after injury?
immediately after injury within 2 hours after injury due to slow bleeding 3 weeks after the injury due to multisystem failure
what are the complications of basilar skull fracture?
increased ICP cranial nerve damage infection
what are the characteristics for epidural hematoma?
initial period of unconsciousness brief lucid interval followed by decrease in LOC headache, nausea, vomiting focal findings neurologic emergency requires rapid evacuation
what are the characteristics for ventriculostomy drain and monitoring?
level with the tragus of the ear central perfusion pressure elevate HOB 30 degrees to prevent increase in ICP at risk for infection
what is a basilar skull fracture?
linear fracture at the base of the skull
what are the different types of skull fractures?
linear or depressed simple, comminuted, or compound closed or open
what are the interventions for hemodynamic support as needed?
maintain BP with vasopressors or vasodilators watch that CPP
what is the focused nursing care for brain injuries?
maintaining circulation maintaining respiratory function preserving cognitive function preventing complications
what are the characteristics for subacute subdural hematoma?
within 2 to 14 days of the injury may appear to enlarge over time
what are the characteristics for acute subdural hematoma?
within 24 hours to 48 hours of injury symptoms related to increased ICP decreases LOC and causes headache ipsilateral pupil dilated and fixed if severe
what is the best diagnostic test to determine craniocerebral trauma?
ct scan
what are the different hypertonic saline solutions?
10% dextrose 5% dextrose in 0.45% sodium chloride 5% dextrose in 0.9% sodium chloride
what is battle's sign?
Bluish discoloration on the area behind the ears (mastoid process).
what are the diagnostics for basilar skull fracture?
CT scan definitive
interventions for peripheral circulation?
STD hose medications
what does ABCs stand for?
airway breathing circulation
what is a head injury?
any trauma to skull, scalp, or brain
what are the purpose of diagnostics to assess for head injury?
assess spinal cord and bleeding in the brain
what is the immediate care for any head injury?
assume spinal injury ABCs diagnostics frequent or continuous vital signs and neuro assessments IV access and cautions for fluid resus assess for and treat other injuries
what are the locations for skull fractures?
based on bone fragmented
what are the causes of brain lacerations?
bone fracture penetrating objects
what are the different kinds of bleeding for brain injuries?
brian lacerations intracranial hemorrhage
what are the characteristics for contusions?
can rebleed focal and generalized manifestations monitor for seizures potential for increased hemorrhage if on anticoagulants
what are the characteristics for concussions?
caused by sport injuries post concussion syndrome is residual effects for longer periods of time
what are assessments for increased ICP for preserving cognitive function?
clinical manifestations measuring ICP
what are the different types of brain injuries?
concussion contusion diffuce axonal injury bleeding
what are the different intracranial hemorrhages?
epidural subdural subarachnoid intracerebral
what is a contusion?
event resulting in bruising of brain tissue
what is a concussion?
event resulting in neuro changes without specific brain damages resolves in 72 hours
what are the characteristics for scalp lacerations?
external head traumas scalp is highly vascular (profuse bleeding) major complications is blood loss and infection
what are the most common causes of head injury?
falls (especially in elderly) motor vehicle accidents
what are other causes of head injury?
firearm-related injuries assaults sports-related trauma recreational injuries war-related injuries
what is the gold standard for assessing changes in LOC?
glasgow coma scale
what is included in the detailed neuro assessment for brain injury patients?
glasgow coma scale pupils (PERRLA, EOMs, gaze, convergence, musculoskeletal, strength, sensation, tone) reflexes (corneal, cough, gag) seizures
what is halo's sign?
halo forms from a drop of blood
what is included in the physical assessment for brain injury patients?
head to toe shift assessment special attention
what is included in the assessment for head injuries?
headache or dizziness nausea seizures memory loss or changes in LOC restlessness and irritability dilated or pin point pupils cheyne stokes posturing effects cushing's triad CSF leak
what are the different health promotions and maintenance for head injuries?
helmets seat belts and other care safeties gun safety fall prevention for older adults sport injuries such as concussion or mild injuries that cause changes everyone should go to the ED or doctor
what is included in the assessment for an individual with a brain injury?
history vital signs physical assessment detailed neuro
what are the different infections that could become complications after a basilar skull fracture?
hospital acquired infections meningitis
what are the interventions for avoiding things that increase ICP?
hypercarbia coughing and suctioning increasing intra-abdominal pressure (restrictive clothing, valsalva maneuver)
what are the medications for maintaining optimal ICP?
mannitol hypertonic saline corticosteroids anti-seizure pain sedation paralytics
what are the nursing implications for fluid and electrolytes?
monitor IV fluids daily electrolytes monitor for DI and SIADH
what are the pain medications for maintaining optimal ICP?
morphine fentanyl
what is the ambulatory and home care for head injuries?
motor and sensory deficits communication issues memory and intellectual functioning nutrition bowel and bladder management seizure disorder mental and emotional difficulties progressive recovery family participation
what are the nursing implications for hypertonic saline solutions?
moves water out of cells and into blood monitor BP and serum sodium levels no hypotonic solution
what are the special considerations for complications?
nutrition skin contractures fluid and electrolytes infection (open head injury, abscess, nosocomial infections)
what are the different cranial nerves that are affected by basilar skull fractures?
ocular tinnitus hearing loss facial paralysis
what are the interventions for airway and breathing as needed?
oxygen sedation and paralysis lower co2 levels prevent cerebral vasodilation
what to assess for maintaining respiratory function?
oxygen and carbon dioxide impact of other injuries on respiratory function such as pneumothorax or atelectasis
what are the characteristics for mannitol?
plasma expansion osmotic effect monitor fluid and electrolyte status
what is the purpose of frequent or continuous vital signs and neuro assessments?
preserve cognitive function
what are the treatment principles for brain injuries?
prevent secondary injuries timely diagnosis observation and management of ICP for concussions and contusions conservative treatment or surgery for skull fractures surgical evacuation for subdural and epidural hematomas
what are the sedation medications for maintaining optimal ICP?
propofol precedex
what to assess for peripheral circulation?
pulses capillary refill
what are the manifestations for basilar skull fracture?
raccoon eyes battle's sign rhinorrhea or otorrhea loss of consciousness followed by period of normal then LOC again nausea and vomiting vision changes facial numbness
what should you do to assess for and treat other injuries?
remove clothing control bleeding and stabilize treat pain and sedate as appropriate maintain normothermia
what to assess for central circulation?
renal perfusion GI
what are the interventions for maintaining respiratory function?
sedation paralytics
what are the characteristics for chronic subdural hematoma?
weeks or months after injury more common in older adults presents as focal symptoms increase risk for misdiagnosis
what are burr holes?
small holes made by a neurosurgeon
what should you do if you assume a spinal injury occurred?
stabilize the neck apply a collar
what is used for intracranial pressure management?
subarachnoid belt fiberoptic catheter ventriculostomy
which hemorrhage is at most risk to rebleed?
subdural
what are the medical management options for brain injuries?
surgical evacuation intracranial pressure management
what is the most serious type of head injury?
traumatic brain injury
what are the nursing implications for corticosteroids?
vasogenic edema monitor fluid intake, serum sodium, and glucose levels concurrent antacids, H2 receptors blockers, proton pump inhibitors
