Hinkle Chapter 68: Management of Patients With Neurologic Trauma

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. What cerebral perfusion pressure should the nurse maintain?

50 to 70 mm Hg to help control increased ICP

The earliest sign of serious impairment of brain circulation related to increased ICP is:

A change in LOC

What finding should the nurse expect in a patient with spinal shock?

Absence of reflexes along with flaccid extremities

This 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

What are possible long-term complications of spinal cord injury?

Autonomic dysreflexia Respiratory infection

What are the components of the Cushing's Triad?

Bradycardia, hypertension, and Respiratory irregularities

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:

Decerebrate

LOC can be assessed based on the criteria in the GCS, which include:

Eye opening, verbal response, and motor response

________ in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection

Fever

What nursing diagnoses are appropriate for a client who has suffered a head injury

Ineffective airway clearance: Apply suction as indicated Disturbed sleep pattern: Provide back rubs to the client Interrupted family process: Encourage the family to join a support group

A GCS score of 13 to 15 is classified as:

Mild TBI

A GCS score of 9 to 12 is classified as:

Moderate TBI

What is an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

Monitor I&O and take daily weights

This is the most common cause of SCI is

Motor vehicle crashes

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

Subdural hematoma

A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

Suction the Airway

The Monro-Kellie hypothesis refers to:

The dynamic equilibrium of cranial contents

What is a key component in planning care of a patient with an epidural hematoma?

The understanding that rapid neurologic deterioration occurs

What needs to reported for a patient who experienced a concussion?

Vomiting - indicates increasing ICP

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

Widening Pulse Pressure

What are the risk factors for spinal cord injury (SCI)?

Young Age Alcohol and/or drug use Male Gender

To help prevent adverse effects of high doses methylprednisolone the nurse expects the physician to order:

famotidine

What should the nurse most encourage the caregiver of a tetraplegic to do to help maintain skin integrity?

regularly relieve pressure Protect from injury Keep clean and dry Avoid wrinkles in the bed Maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin

Symptoms progressively worsen in a client with an ______ subdural hematoma within the first 24 hours of the head injury

Acute

A type of neurogenic pain whereby clients experience pain in response to a normally painless stimulus

Allodynia

A "Battle sign" may indicate a basilar skull fracture in a patient who has sustained a head injury. What is a "battle sign"?

An area of bruising over the mastoid bone

Fluid leaking from the patient's ears is a probable sign of which type of skull fracture?

Basilar

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

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

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

C5

Results from a blow to the head that jars the brain

Concussion

Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a:

Contrecoup injury

This results in bruising, and sometimes, hemorrhage of superficial cerebral tissue

Contusions are

To assist in controlling ICP in clients with severe brain injury, the following are recommended:

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)

Bleeding between the inner skull and the dura, compressing the brain underneath

Epidural hematoma or extradural hematoma

This type of spinal nerve root compression involves the tissues surrounding the spinal cord

Extramedullary

To detect any CSF drainage, the nurse looks for a ________ sign, which is a blood stain surrounded by a clear or yellowish stain

Halo

What are characteristics of autonomic dysreflexia?

Hypertension Tachycardia Bradycardia Severe, pounding headache Flushed skin/Diaphoresis Nausea Nasal congestion

Posttraumatic seizures are classified as ______ (within 24 hours after injury), ______ (within 1 to 7 days after injury), or ______ (more than 7 days after injury)

Immediate, Early, Late

A client has sustained a traumatic brain injury. What is the priority nursing diagnosis for this client?

Ineffective Airway Clearance

A client is admitted with a cervical spine injury sustained during a diving accident. What is the priority nursing diagnosis?

Ineffective breathing pattern

bleeding in the brain or the cerebral tissue with displacement of surrounding structures

Intracerebral hemorrhage

This type of spinal nerve root compression involves the spinal cord

Intramedullary

What is the benefit of the halo device usage in a patient who has sustained a SCI?

It allows for stabilization of the cervical spine along with early ambulation.

An epidural hematoma is 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.

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?

Place the patient in a sitting position

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

Spasticity

This is an acute complication of SCI

Spinal Shock

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?

Sympathetic Nervous System

When the head is struck directly, the injury to the brain is called a:

Coup injury

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

It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage

___________ injury results from the initial damage from the traumatic event.

Primary

What is the priority nursing diagnosis for client who is disoriented and restless after sustaining a concussion during a car accident?

Risk for injury

___________ injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.

Secondary

This results from inadequate delivery of nutrients and oxygen to the cells.

Secondary brain injury

A GCS score of 3 to 8 is classified as:

Severe TBI

Autonomic dysreflexia can occur with spinal cord injuries above

T6

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

Traction with weights and pulleys