Head Injury ATI

head injury classifications
open or penetrating trauma; closed or blunt trauma

open or penetrating trauma
skull integrity compromised

closed or blunt trauma
skull integrity maintained

head injuries also classified depending on Glasgow Coma Scale as
mild, moderate or severe and length of time the client was unconscious

open-head injuries pose a high risk for

skull fractures are often accompanied by
brain injury

damage to the brain tissue may be the result of
decreased oxygen supply, or the direct impact from the skull fracture, which caused the trauma

which levels are altered in the brain negatively?

negative glucose levels result in an
alteration in neurologic synaptic ability

head injuries may be associated with
hemorrhage (epidural, subdural, and intracerebral) or cerebrospinal fluid leakage

any collection of fluid or foreign objects that occupies the space within the skull poses a risk for
cerebral edema, cerebral hypoxia, and brain herniation

always suspect this when there is a head injury
cervical spine injury

______ (3) must be ruled out prior to removing any devices used to stabilize ____ _____
cervical spine injury; cervical spine

health promotion topics
wear a helmet; wear seat belts; avoid dangerous activities

risk factors for head injuries
males under 25; motor vehicle/motorcycle crashes; age 65-75; drug and alcohol use; sports injuries; assault; gunshot wounds; falls

assess these when head injury
presence of alcohol or illicit drugs at time of injury; amnesia before or after injury; loss of consciousness and length of time of loss of consc; signs and symptoms; labs; diagnostic procedures

signs and symptoms of increased intracranial pressure
severe headache; deteriorating level of consciousness, restlessness, irritability; dilated pinpoint, or asymmetric pupils, slow to react or nonreactive; alteration in breathing pattern (Cheyne-Stokes respirations, central neurogenic hyperventilation, apnea); deterioration in motor function, abnormal posturing; cushing reflex (late finding); CSF leakage from nose and ears; and seizures

cushing reflex manifestions
severe hypertension with a widening pulse pressure and bradycardia (decreased diastolic pressure)

CSF leakage is characterized by
halo sign – yellow stain surrounded by blood on a paper towel; fluid tests positive for glucose

lab tests to analyze
ABGs, blood alcohol and toxicology screen, CBC with differential and BUN

diagnostic procedures
cervical spine films to diagnose injury; CT and or MRI of head and/or neck (with or without contrast)

what is the golden window?
it is a one hour time frame for treatment of head injuries that helps decrease morbidity and mortality, especially with epidural hematomas

nursing assessment at regular intervals
respiratory status, changes in level of consciousness, cranial nerve function, pupillary changes (PERRLA), findings of infection, bilateral sensory and motor responses, intracranial pressure

expected reference range for ICP is

four methods of measuring/monitoring ICP
thin tube inserted into lateral ventricle; bolt or screw placed in the subarachnoid area; place a sensor in the epidural space; fiberoptic transducer-tipped catheter into the subdural or subarachnoid space, ventricle or brain tissue

causes of increased ICP
hypercarbia, endotracheal or oral tracheal suctioning, coughing, blowing the nose forcefully, extreme neck or hip flexion/extension, maintaining the head of bed at an angle less than 30, increasing intra-abdominal pressure (restrictive clothing, valsalva maneuver)

secondary brain injury results from
hypotension, hypoxia, hyperglycemia, hypoglycemia, acidosis, and hypercapnia

mannitol is
an osmotic diuretic used to treat cerebral edema

pentobarbital is
used to induce a barbiturate coma to decrease cerebral metabolic demands

a barbiturate coma is a treatment of
last resort and aims to decrease elevated ICP by inducing vasoconstriction and decreasing cerebral metabolic demands

phenytoin is
used prophylaactically to prevent or treat seizures

morphine sulfate and fentanyl are
analgesics used to control pain and restlessness

when should you avoid opioid use?
if a client is not mechanically ventilated due to CNS depressant effects; may cause respiratory depression; prevents accurate assessment of neuro

what is a craniotomy?
the removal of nonviable brain tissue that allows for expansion and/or removal of epidural or subdural hematomas

potential severe complications for craniotomy
severe neurological impairment, infection, persistent seizures, neurological deficiencies and/or death

complications with head injuries
herniation; hematoma; intracranial hemorrhage; neurogenic pulmonary edema; diabetes insipidus; SIADH; cerebral salt wasting

herniation is
the downward shift of brain tissue due to cerebral edema

monro-kellie doctrine states that
any alteration in the volume of one of brain matter, cerebrospinal fluid, intravascular blood results in a compromise in the others

signs and symptoms of herniation
fixed dilated pupils, deteriorating level of consciousness, Cheyne-Stokes respirations, hemodynamic instability, and abnormal posturing

recovery for herniation
rare; urgent – requires mannitol and/or surgical (debulking) treatment

signs and symptoms of a hematoma/intracranial hemorrhage
severe headache, rapid decline in level of consciousness, worsening neurological function and herniation and changes in ICP

treatment for hematoma/intracranial hemorrhage
surgery is required to remove subdural and epidural hematoma; hemorrhage is treated with osmotic diuretics

neurogenic pulmonary edema s/s
mimic pulmonary edema without cardiac involvement

Cerebral salt wasting is caused by
effects of atrial natriuretic factor (ANF) located in the hypothalamus

Increased ANF production causes what?
decreased sodium retention in the kidneys; may also prevent renin and aldosterone release

cerebral salt wasting causes
decreased serum osmolality and hyponatremia

CSW is the primary cause of
hyponatremia following neurosurgery

nursing interventions for CSW
monitor serum electrolytes and osmolality daily; document strict I&O; daily weights; treat electrolyte and fluid imbalance as prescribed; monitor for dehydration or fluid overload during treatment

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