Med Surg Nursing Neuro
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
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