Med Surg Nursing Neuro

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Med Surg Nursing Neuro

By | July 2013
Page 1 of 8
Ch. 56-61 (cont)

Head Injury
-trauma to head, including chg in LOC
-traumatic brain injury= incr potential for poor outcome
-immediately after, 2h after, 3 wk after, death common

-*abnormal motor reflex, alt eye mvmt, hypotension= hypoxia= decr O2 in brain, incr ICP greater than 20

GCS measures speech, eye, motor
-if greater than 8= 90% chance recov
-if less than 8= 30-70% chance recov

Scalp lac- most common type, profuse bld, complication is infx -skull fx- linear, depressed, simple, comminuted, compound, closed, open -velocity, what did head hit?

-*LOC of fracture alters manifestation
-basilar @ base of skull= Battles sign
*conjug deviation of gaze
*assess for bruising behind ear (Battles)
*rhinorrhea/otorrhea- CSF leak

Minor head trauma- concussion= brief LOC, amnesia, headache
-short duration

Post Concussive Syndrome- lasts 2w-2m
-persistent headache, lethargic, short attention span, long-term mental probs, change in intellect ability, behavioral changes

Diffuse Axonal Injury (DAI)
-widespread axonal damage following any traumatic brain injury -*decr LOC
-*incr ICP
-*decortic/decerebr
-*global cerebral edema

Major head trauma
-contusion- bruising of brain tissue w/in focal area of pia/arachnoid layers

Coup- Brain accelerates forward to skull- primary impact
Countrecoup- brain back to skull- second impact (decel)

Lacerations
-tearing of brain tissue
-depressed & open fx, penetr injuries

Intracerebral hemorrhage
**ABX ASAP!
**O2!

Epidural hematoma- blood b/w dura & inner surface of skull
-**neurologic emergency
Sx: period of LOC, lucid interval followed by decr in LOC, headache, N/V, focal findings

**if incr ICP, do NOT DO LP bc brain goes down (herniation) into SC

Subdural hematoma-blood b/w dura & arachnoid space
-acute 24-48 hr of injury
-sx similar to brain tissue compress in incr ICP
-drowsy/confused
-ipsilateral pupils dilate & fixed

Intracerebral hematoma- blood in...

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