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TBI, CHI, SCI
| Question | Answer |
|---|---|
| S/Sx: -↓ LOC -otorrhea -rhinorrhea -Battle sign -Halo sign -raccoon eyes -pupil changes (unequal) -vomiting (projectile) -HA -fatigue/lethargy | traumatic brain injury (TBI) |
| a temporary loss of neurologic function with no apparent structural damage to the brain; mild TBI; effects are usually temporary but can include HAs and problems w/concentration, memory, balance and coordination; usually caused by a blow to the head | concussion |
| used to diagnose a skull fracture | computed tomography (CT) scan |
| used to diagnose brain injury; provides better resolution and clearer pictures of the injured area | magnetic resonance imaging (MRI) |
| results from widespread shearing and rotational forces that produce damage throughout the brain—to axons in the cerebral hemispheres, corpus callosum, and brainstem; pt develops immediate coma | diffuse axonal injury (DAI) |
| most common TBI; brain suddenly moves forward in one direction in a linear path; causes injury at the site of impact; ex: hit in head with fist or bat assault victims | acceleration injury |
| brain stops rapidly in the cranial vault; skull ceases movement but brain keeps going until hits the skull; ex: fall | deceleration injury |
| term for when acceleration injury occurs together with deceleration injury? | coup-contrecoup |
| force impacting the head transfers the energy in a non-linear fashion; result shearing forces throughout the brain; ex: boxing - tearing of axons in the brain; can result in spinal cord injury | rotational injury |
| foreign object invades the brain; mass pass through or bounce around inside; ex: bullet, knife, falling object | penetrating injury |
| most benign/nonfatal skull fracture; break in the continuity of the bone; low velocity blunt trauma; seen on CT; allowed to heal without OR | simple (linear) fracture |
| a force depresses skull inward; visible or palpable; may tear meninges of brain; high probability of sustainable injury; requires surgery (elevation of the skull and débridement); nursing focus neuro assessments & pain mgt. | depressed fracture |
| accompanied by scalp laceration; high risk for infection; wet-to-dry drsg; req. surgical repair - debridement of wound; neuro checks, pain management; ATBs | open fracture |
| high impact head injury; fracture to bones at base of skull; S/Sx: periorbital ecchymosis, mastoid ecchymosis (Battle sign), otorrhea, rhinorrhea, hemotympanum, facial nerve paralysis, Halo ring | basilar fracture |
| Tx: allow CSF to drain & dura to close on its own (1-2 weeks); neuro checks; pain mgt, s/sx infection, drsg changes (aseptic tech) sterile gauze under nose | basilar fracture |
| T or F? Contusion is a temporary loss of neurologic function with no apparent structural damage to the brain. | False (A concussion is a temporary loss of neurologic function with no apparent structural damage to the brain; contusion is a bruising of the brain surface.) |
| fractures of 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 ___, ___, or ___, and blood may appear under the conjunctiva | nose, pharynx, ears |
| an area of ecchymosis may be seen over the mastoid | Battle sign |
| basal skull fractures are suspected when ___ escapes from the ears (otorrhea) and the nose (rhinorrhea) | CSF |
| drainage of ___ is a serious problem, because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura | CSF |
| blood components separate from the CSF, creating a clear ring surrounding a bloody spot | halo (or double ring) sign |
| T or F? Clear rhinorrhea from the nose is a sign of a basilar fracture. | True (Signs of basilar fracture include CSF drainage from the ears or nose, bleeding from the nose or ears, Battle’s sign (ecchymosis found on the mastoid), and halo sign (ring of fluid around blood stain from drainage). |
| pt having seizure...give what med immediately that quickly works to stop seizure? (very thick/sticky...has to be diluted with NS) | lorazepam/Ativan |
| blunt trauma to head, mild TBI; temp. loss of neuro function w/no apparent structural damage to brain; Sx: transient period of unconsciousness ~20 min, GCS=13-15; may report amnesia of injury, HA, dizziness, vertigo, slurred speech, vomit, confusion | concussion |
| bruising of brain surface; more severe injury w/possible surface hemorrhage; Sx and recovery depend on amount of damage and associated cerebral edema; longer period of unconsciousness with more Sx of neurologic deficits and changes in vital signs | contusion |
| when bleeding occurs b/w the tough outer membrane covering the brain (dura mater) and the skull; caused by high impact to temporal areas; small arteries sheared | epidural hematoma |
| Sx: brief loss of consciousness, then A&O, then unconscious again; may have fixed dilated pupil on side of impact; quick ID important or arterial bleeding leads to ↑ICP, herniation | epidural hematoma |
| collection of blood b/w dura and brain (space normally occupied by a thin cushion of fluid); most common cause is trauma, but can also occur as a result of coagulopathies or rupture of an aneurysm; acute < 48 hrs, subacaute 48 hrs–2 wks, chronic > 2 wks | subdural hematoma (SDH) |
| Sx: drowsy, HA, confusion, slowed thinking, agitation, vomiting, seizures, stiff neck, pupil changes, hemiparesis; Tx: evacuate hematoma, place drain; monitor LOC, neuro checks, drain care | subdural hematoma (SDH) |
| blood accumulates in the parenchyma of brain tissue; result from uncontrolled HTN, ruptured aneurysm, high impact blow to head, trauma; Sx: HA, ↓LOC, dilation of 1 pupil, hemiplegia; Tx: medical management of ICP & CPP | intracerebral hematoma (ICH) |
| Glasgow Coma Scale (GCS) useful to determine severity of injury: Mild alteration LOC GCS= ? Moderate injury GCS= ? Severe injury GCS = ? | mild 13-15 moderate 9-12 severe 3-8 |
| accumulation of blood in arachnoid layer of brain; leaks into CSF; Sx: nuchal rigidity, severe HA, range from focal bleed to massive bleed w/intercranial hypotension; neuro checks, pain mgt, ↓ICP, ↑ CPP, stabilize VS, early DC planning, rehab | subarachnoid hemorrhage (SAH) |
| -pt may be admitted for obs or sent home -observe for: changes in LOC, difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety; difficulty in speaking or movement; severe HA; vomiting; pt should be aroused and assessed frequently | concussion |
| with head injuries always assume ___ ___ ___ until it is ruled out; reposition pt using? | cervical spine injury; log roll |
| best IV fluid(s) to give for pt with head injury? | hypertonics (D5s) and blood products ***never give hypotonic (1/2NS) b/c it will cause cells to swell) |
| loss of ADH secretion d/t damage to pituitary gland from TBI; Sx: polyuria, polydipsia; Tx: replace fluids and replace ADH as vasopressin or desmopressin IV, SQ, intranasal; should see ↓ urine output and ↑ spec. gravity | Diabetes Insipidus |
| excess of ADH, retain H2O; Sx: ↓ urine output, retain Na+ --- leads to cellular swelling, ↑ ICP as 2nd injury; Tx: fluid restriction, monitor I&0, neuro checks | Syndrome of Inappropriate Antidiuretic Hormone (SIADH) |
| state of hypovolemia, loss of Na+ in urine H2O follows; Tx: fluid and salt replacement; corrects self in 3-4 weeks | cerebral salt wasting |
| major causes of spinal cord injuries? | MVAs (46%), falls (22%), violence (16%), sports injuries (12%) |
| transient disturbance of spinal cord function, with or w/o vertebral damage and no demonstrable pathologic changes, that results from a rapid change in velocity following trauma, and resolves within 48 hours; severe shaking of the cord | spinal cord concussion |
| bruising associated with bleeding into cord; subsequent edema and possible necrosis; usually implies some permanent neuro deficit b/c cord tolerates compression very poorly | spinal cord contusion |
| an actual tear in the cord results in permanent injury; contusion, edema, and cord compression accompany this; can result in complete cord transection | spinal cord laceration |
| severing of cord – can be complete or incomplete; complete is rare, although clinical presentation is frequently seen | transection |
| bleeding into or around the cord acts as an irritant to the delicate tissue, resulting in changes in the neurochemical components, edema, and neuro deficits | hemorrhage |
| S/Sx: -numbness, paresthesias, paralysis -change in mental status -decrease function -resp. distress, bradypnea | spinal cord injuries |
| first-line treatment for spinal cord injuries | C-collar, keep neck stable |
| sudden depression of reflex activity below level of spinal injury; onset: 30-60 min-several hours; Sx: ↓ B/P and HR, flaccid paralysis, absent muscle tone, bowel & bladder dysfnc.; duration: 7-20 days (resolves spont); Tx: treat sx | spinal shock |
| caused by the loss of function of the ANS; Sx: venous pooling occurs because of peripheral vasodilation, paralyzed portions of the body do not perspire; ↓ BP/HR/CO, hypothermia; Tx: fluids & vasopressors | neurogenic shock |
| a life-threatening emergency in patients with spinal cord injury that causes a hypertensive emergency; occurs after spinal shock has resolved and may occur years after the injury; SC lesions at or above T6; ANS responses are exaggerated | autonomic dysreflexia (also called autonomic hyperreflexia) |
| Sx: severe/pounding HA, sudden ↑ B/P, bradycardia, profuse diaphoresis, nausea, nasal congestion; triggering stimuli include distended bladder (most common), distention or contraction of visceral organs (e.g., constipation), stimulation of the skin | autonomic dysreflexia (also called autonomic hyperreflexia) |
| Pt w/SCI at T5 begins to c/o severe HA, diaphoretic & nauseated. Intervention would not be appropriate? -Place pt immediately in a sitting position -Lower pt to a flat, sidelying position -Assess for bladder distention -Assess rectum for fecal mass | Lower pt to a flat, sidelying position |
| LOC can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. -Eye opening -Verbal response -Motor response -Intelligence -Muscle strength | -Eye opening -Verbal response -Motor response (The pt's responses are rated on a scale from 3-15. Intelligence and muscle strength are not measured in the GCS.) |
| S/Sx of Cushing’s triad | -HTN -Bradycardia -Bradypnea |
| In SCI, neurogenic shock develops d/t loss of ANS functioning below level of lesion. Which indicators of neurogenic shock would the nurse expect to find? (Select all) -Hypotension -Tachycardia -Venous pooling -Diaphoresis -Tachypnea -Hypothermia | -Hypotension -Venous pooling -Tachypnea -Hypothermia |
| Which of the following are the immediate complications of spinal cord injury? (select all) -Respiratory arrest -Tetraplegia -Spinal shock -Paraplegia -Autonomic dysreflexia | -Respiratory arrest -Spinal shock |
| Clinical manifestations of neurogenic shock include which of the following? (Select all) -Venous pooling in the extremities -Bradycardia -Warm skin -Tachycardia -Profuse bilateral sweating | -Venous pooling in the extremities -Bradycardia -Warm skin |
| Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? (Select all) -Hemiparesis -Tachypnea -Decreased reactivity of the pupils -Bradycardia -Hypotension -Coma | -Hemiparesis -Decreased reactivity of the pupils -Bradycardia -Coma |
| The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply. -HTN -Tachycardia -Fever -Diaphoresis -Nasal congestion | -HTN -Diaphoresis -Nasal congestion |
| Nurse is caring for a pt w/TBI. Which clinical finding, observed during the reassessment of the pt, causes nurse the most concern? -Temp ↑ from 98.0°F to 99.6°F -UO ↑ from 40 to 55 mL/hr -HR ↓ 100 to 90 bpm -Pulse ox ↓ from 99% to 97% room air | Temp ↑ from 98.0°F to 99.6°F |
| A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: -Mild TBI. -Moderate TBI. -Severe TBI. -Brain death. | Severe TBI. (A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI.) |
| Pt brought to hospital after a skiing accident; unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to hospital for Tx. Pt became very agitated and restless, then quickly lost consciousness again. Type of TBI? | epidural hematoma |
| 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)? -Epidural -Subdural -Intracerebral -Contusion | Epidural |
| Pt brought to ED by family after falling off roof. Care team suspects epidural hematoma, prompting nurse to prepare for? -Insertion of an intracranial monitoring device -Tx w/antihypertensives -Making openings in skull -Anticoag therapy | Making openings in skull (Epidural hematoma is considered an extreme emergency. Marked neuro deficit or resp arrest can occur w/in minutes. Tx consists of making an opening through the skull to decrease ICP emergently, remove clot, and control bleeding) |
| Pt 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? -An epidural hematoma -An extradural hematoma -An intracerebral hematoma -A subdural hematoma | An intracerebral hematoma (Intracerebral hematoma is bleeding w/in brain, into the parenchyma of brain. It's commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). |
| Nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? -Hypophysectomy -Application of Halo traction -Burr holes -Insertion of Crutchfield tongs | Burr holes |
| Which of the following types of skull fractures may be evident by Battle’s sign? -Basilar -Simple -Comminuted -Depressed | Basilar |
| Pt who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include? -Preparation for emergency craniotomy -Watchful waiting and close monitoring -Administration of inotropic drugs -Fluid resuscitation | Watchful waiting and close monitoring (Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the client is essential.) |
| CT scan demonstrates a fracture in which the fragments of bone are driven inward. This type of fracture is referred to as -depressed. -compound. -comminuted. -impacted. | depressed. |
| According to the _______, the cranial vault is a closed system, and if one of the three components increases in volume, at least one of the other two must decrease in volume, or the pressure will increse. | Monro-Kellie doctrine |
| A ____ after head injury is a temporary loss of neurologic function with no apparent structural damage. | concussion |
| The three criteria used to assess LOC using the Glasgow Coma Scale are ____, _____, and _____. | -eye opening -verbal responses -motor responses to verbal commands or painful stimuli |
| type of SCI? -motor weakness or complete paralysis -hemiplegia on same side as cord damage -hemianesthesia on opposite side of cord damage | Brown–Séquard |
| type of SCI? -loss of pain, temp, and motor function is noted below the level of the lesion -light touch, position, and vibration sensation remain intact (proprioception) | anterior |
| med given for low heart rate? | atropine |
| med given for low BP? | norepinephrine/Levophed |
Created by:
nurse savage
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