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Neurological Spinal
Neurological and Spinal Trauma
| Question | Answer |
|---|---|
| Head injuries | include injuries to scalp, skull or brain. Most common cause of death from trauma in U.S., most common causes = MVA, violence, falls, sports |
| The most serious type of head injury is | traumatic brain injury TBI |
| head injury and the elderly = | 5th leading cause of death |
| NORMAL ICP is | 10-15, BUT for post craniotomy its 15-20 |
| Norma ABG PH is | 7.35-7.45 |
| nursing assessment and monitoring | assume pt has a cervical spine injury until proven otherwise (xray), alcohol and drugs may mask symptoms of deterioration and can mask Increased ICP |
| Cushing reflex | severe HTN with a widened pulse pressure and bradycardia |
| Pt with head injury the nurse should teach the pt to avoid what? | Coughing and nose blowing because increase ICP |
| With head injury the environment should be | calm and restful for this ---> limit visitors, minimize noise alternate activities with rest periods, implement seizure precations |
| What is battles sign and raccoon eyes sign? These indicate skull fractures ( bleeding from nose, pharynx, ears or into conjunctiva) | Battle sign is bruising(ecchymosis) over mastoid . Raccoon - Bilateral periorbital ecchymosis |
| TBI (traumatic brain injury) - Blunt injuries or deformation injuries | occurs when an object strikes the head, often results in skull fractures, concussion, contusion or intracranial hemorrhage |
| TBI - for MVA | causes acceleration and deceleration injuries, often result sin contusion and intracranial hemorrhage |
| a concussion is a | violent jarring or shaking that results in a disturbance of brain function |
| intracranial hemorrhage | most serious type of brain injury. Hematoma: collection of blood. s/s, pupillary changes, hemiparesis, HTN, bradycardia, bradypnea |
| Subdural hematoma (BOXERS) | blood collects between the dura mater and the arachnoid mater, often originating from venous hemorrhage. Chronic (over 2 wks), Acute (48 hrs), RESEMBLES STROKE SYMPTOMS. |
| Intracerebral hemorrhage | may be insidious, headaches, neurologic deficits, bleeding collects within the brain tissue. Bleeding causes displacement of brain tissue (destroys brain tissue, causes cerebral edema, increase ICP) |
| a pt has clear fluid leaking from the nose following a basilar skull fracture. The nurse determines that this is cerebrospinal fluid if the fluid | seperates into rings and tests positive for glucose |
| a man is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse would plan on leaving the cervical collar in place until | the results of the spinal xrays are known |
| SCI | Spinal cord injury |
| S/S of SCI | loss of motor/sensory function, reflexes, control of elimination |
| Respiratory complications is from | c3-c5 |
| Quadraplegia = | paralysis form the next down; paralysis of all limbs. Also known as tetraplegia |
| paraplegia/paresis= | 2 lower extremities |
| complete transection of the cord | complete SCI = loss of all innervation below the level of the injury |
| Incomplete transection | incomplete SCI=some function below the level of the injury |
| spinal cord injury thoracic | damage to thoracic region through L1,L2 - paraplegia -2 lower extremities. LOSS of vasomotor one, sweating, and possible paraplegia or quadriplegia below level of injury |
| Thoacic injuries | loss of normal bowel and bladder control, numbness, breathing difficulties |
| Lumbar injuries | loss of bowel and bladder control |
| The pt received a high dose of corticossterioids prior to being admitted to the neuro step down unit. what does the nurse need to be on the watch out for because of this medication? | Infection |
| What does the nurse do if she suspects the client is experiencing autonomic dysreflexia? | Put the head of the bed up |
| The nurse should question which of the following prescribed intervention for the patient with SCI? | Administration of atropine to treat tachycardia! (It treats bradycardia) |
| Which patient is most at risk for respiratory compromise post spinal cord injury? | C3-C4 |
| A patient with cervical spine injury has crutchfield tongs applied in the ED. The nurse would avoid which of the following when planning care for this pt | Romoving weights to reposition the patient |
| A pt with spinal cord injury is prone to experiencing autonomic dysreflexia. the nurse would avoid which measure to minimize the risk of recurrence? | limited bladder catheterization to once every 12 hrs |
| autonomic dysreflexia also known as hyperreflexia . A pt with spinal cord injury is prone to experiencing autonomic dysreflexia | Means an over activity of autonomic nervous system causing an abrupt onset of excessively high blood pressure |
| list 3 common causes of autonomic dysreflexia | anything painful, uncomfortable, or physically irritating before the injury may cause autonomic dysreflexia after the injury. Most common cause seems to be overfilling of the bladder. The second most common cause is a bowel that is full of stool or gas. |
| What is the nurses response to neurogenic shock? | MX for bradycardia, hypotension, orthostatic hypotension and DVT |
| list for commonly prescribed medications administered post SCI? | glucocorticoids - suppress immune response, vasopressors - treat hypotension, atropine - treat bradycardia, anticoagulants for DVT prevention |
| what is the most common cause of death from trauma in the US | Head Injury |
| What is the 5th leading cause of death in the elderly? | Head injury |
| What is normal ICP range? | 10-15 mmHG |
| What are the three components of the Glasgow Coma Scale? | Eye opening score of 1: does the patient open eyes when spoken to? Verbal score of 3: can the person speak? Motor response of 4: if you prick with a pin, will the patient withdraw? |
| Describe Coup-Countrecoup | in head injury coup injury occurs under the site of impact with an object. Contrcoup injury occurs on the side opposite the area that was impacted. Coup and contrecoup injury is associated with cerebral contusion, type of TBI in which the brain is bru |
| Ph | 7.35-7.45 |
| Co2 | 35-45 |
| O2 | 80-100 |
| HCO3 | 22-26 |
Created by:
starr8904
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