Prep U ch 63 management of patients with neurologic trauma

periorbital ecchymosis

(raccoon's eyes from basilar scull fracture

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

* Widened pulse pressure (cushion reflex) * slowing of the heart rate (bradycardia), * increasing systolic blood pressure, 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).

Normal ICP ranges (cerebral profusion pressure)

50 - 70 mm Hg

Glasgow coma scale

A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

GCS score 7 is coma

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.

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

Absence of reflexes along with flaccid extremities 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.

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

Battle's sign

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

Which symptom is an early sign of UTI in a client with a spinal cord injury?

Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

Level of Conciousness (LOC) Assessment

Glasgow Coma scale

Hernia

Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure.

GCS 13 - 15

Mild TBI

GCS 9 - 12

Moderate TBI

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

Monitoring the patency of an indwelling urinary catheter

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

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.

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

Place in seated position

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

Placing the blanket over the pt. An object on the skin or skin pressure may precipitate autonomic dysreflexia. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

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

Secondary injury evolves over the ensuing hours and days after the initial injury and can be due to cerebral edema, ischemia, seizures, infection, hyperthermia, hypovolemia, hypoxia.

GCS 3 - 8

Severe TBI Score 8 or < indicatesan unconscious patient;

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

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.

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

Spinal shock The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury.

acute

Subdural hematomas

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

T 6

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

The change of conciousness

The Monro-Kellie hypothesis refers to which of the following?

The dynamic equilibrium of cranial contents The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others.

grades of concussion or mild traumatic brain injury

There are 3 graades

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

They help prevent the development of contractures."

sign of increasing intracranial pressure and should be reported immediately

Vomiting

Autonomic dysreflexia

an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides.

Traction with weights and pulleys

applied to provide correct vertebral alignment and to increase the space between the vertebrae.

cervical injuspinery

can cause respiratory distress

3 cardinal signs of brain death on clinical examination

coma, absence of brain stem reflexes, and apnea.

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:

famotidine or pepcide 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).

Grade 2 of concussion or TBI

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.

Grade 1 of concussion or TBI

has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes.

increased intracranial pressure signs

headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

The most concerning with TBI patients during reassessment is

high Temperature or fever 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 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?

inserting nasogastric tube 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.

Autonomic Dysreflexia

is a long-term complication of SCI.

Autonomic dysreflexia

is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides.

spasticity

is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes

Tetraplegia

is paralysis of all extremities after a high cervical spine injury.

PERSISTENT VEGATATIVE STATE (PVS)

is the phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function.

akinetic mutism

is the phrase used to refer to unresponsiveness to the environment.

Battle sign

may indicate a skull fracture. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid (CSF) leak. Escape of CSF from the client's ear is termed otorrhea. Escape of CSF from the client's nose is termed rhinorrhea.

Paraplegia

occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI. is a long-term complication of SCI.

Ataxia

refers to impaired ability to coordinate movement.

Myoclonus

refers to restlessness, an urgent need to move around, and agitation

Akathisia

refers to spasm of a single muscle or group of muscles.

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

respiratory arrest and spinal shock

Tetraplegia

results in the paralysis of all extremities when there is a high cervical spine injury.

characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating Hypertension, tachycardia, bradycardia, and flushed skin would occur.

GCS 3 and <

severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response;

chushing's response

the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intercranial pressure.

Spinal cord injury C 5

the patient should have full head and neck control, shoulder strength, and elbow flexion

C 4

the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement

C 2 - 3

the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.

Grade 3 of concussion or TBI

there is any loss of consciousness lasting from seconds to minutes

autonomic dysreflexia

utonomic dysreflexia (AD) is a dangerous condition that occurs when the autonomic nervous system overreacts. It can develop after a spinal cord injury , usually at or above the T6 level.