Timby's Introductory Medical-Surgical Nursing: Chapter 39: Caring for Clients w/ Head and Spinal Cord Trauma Flashcards


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1

results from a blow to the head that jars the brain

Concussion

2

This client presents w/:

  • a brief lapse of consciousness
  • with temporary disorientation
  • headache
  • blurred or double vision
  • emotional irritability
  • dizziness

Concussion

3

Medical management for clients w/ concussion

  • client's activity is temporarily halted until seriousness of injury is determined
  • mild analgesics
  • observe clients over the course of their lifetime for neurological issues

4

Nursing management for clients w/ concussion

  • neurologic assessment (observe for IICP)
  • instruct client and family to return to ER if s/s of IICP occur

5
  • results in bruising, and sometimes, hemorrhage of superficial cerebral tissue
  • can lead to gross structural injury to the brain
  • a skull fracture can occur with this

Contusion

6

when head is struck directly with a contusion

croup injury

7

when dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull

Contrecoup injury

8

This client presents w/:

  • hypotension
  • rapid pulse
  • shallow breathing
  • loss of consciousness, but can respond to strong stimuli
  • clammy skin
  • antegrade amnesia (partial/complete inability to recall the recent past; memories before the traumatic event remain in place)

Contusion

9

What is performed to rule out or confirm a skull fracture?

Skull radiography

10

Medical management for client's with a contusion?

manage client's vital functions with drug therapy and mechanical ventilation

11

Nursing management for client's with contusion?

  • observe for changes in LOC, signs of IICP, neuro changes, respiratory distress, and changes in vitals q 1-2 hours
  • Stress the importance of the following:

- using seatbelts for all passengers in automobiles

- restraining infants in approved car seats located in the rear seats of the automobiles

- wearing protective headgear while riding bicycles or motorcycles, skiing, and when participating in contact sports

- raising neck restraints on the back of car seats

- not driving under the influence

12

bleeding within the skull

  • clients @ high risk for this are those receiving anticoagulant therapy or those w/ an underlying bleeding disorder (hemophilia, thrombocytopenia, leukemia, and aplastic anemia)
  • bleeding increases the volume of brain contents and ICP, which disrupts blood flow and causes the brain to become ischemic and hypoxic

Cerebral Hematoma

13

Medical management for clients w/ a cerebral hematoma

a rapid change in LOC and signs of uncontrolled IICP indicate a surgical emergency

14

Surgical management for clients w/ a cerebral hematoma?

  • trephining
  • craniotomy
  • craniectomy
  • cranioplasty

15

surgery that consists of draining holes (burr holes) in the skull to relieve pressure, remove clots in brain, and stop bleeding

trephining

16

surgical opening of the skull to gain access to structures beneath the cranial bones

  • performed to remove blood clot or tumor, stop intracranial bleeding, or repair damaged brain tissues and vessels

craniotomy

17

removal of a portion of a cranial bone

craniectomy

18

repair of a defect in a cranial bone

cranioplasty

19

complications associated w/ intracranial surgery

  • cerebral edema
  • infection
  • neurogenic shock
  • fluid and electrolyte imbalance
  • venous thrombosis (esp. in arms and legs)
  • IICP
  • seizures
  • leakage of CSF
  • stress ulcers
  • hemorrhage

20

What should the nurse monitor for when administering mannitol

  • crystal formation
  • an in-line filter is recommended to use during the administration of 15%, 20%, and 25% solutions

21

Nursing management for clients hematomas?

  • a head injury, no matter how mild it appears, is an emergency
  • obtain hx of the injury and do a neuro assessment, paying particular attention to vitals; loc; presence or absence of movement in arms and legs; pupil size, equality, and reaction to light
  • if trauma caused the head injury, the nurse examines the head for bleeding, abrasions, and lacerations
  • evaluate respiratory status (pay attention to client's ability to maintain adequate hydration)
  • report neuro changes immediately

22

Pre-op care for clients getting a cranial surgery

  • use electric hair clippers to remove hair were burr holes will be place
  • take vitals and record continuing neuro assessment findings
  • administer prescribed meds (phenytoin to reduce risk for seizures, osmotic diuretic *mannitol*, corticosteroids)
  • restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent post-op vomiting
  • inserts indwelling catheter and IV line
  • antiembolism stockings

23

Post-op care for clients getting a cranial surgery

  • place client in supine position with head slight elevated or side-lying position on the unaffected side
  • perform neuro and post op assessments q 15-30 minutes
  • maintain a neuro flow sheet to compare trends in assessment findings
  • periorbital edema and ecchymosis may be present
  • remove antiembolism stockings briefly q 8 hours and reapply
  • monitor body temperature (avoid hyperthermia: manage w/ antipyretics)
  • observe for IICP
  • restrict fluids to control cerebral edema and to increased cerebral perfusion

24

REVIEW NURSING CARE PLAN 39-1: CARE OF THE CLIENT UNDERGOING INTRACRANIAL SURGERY

REVIEW NURSING CARE PLAN 39-1: CARE OF THE CLIENT UNDERGOING INTRACRANIAL SURGERY

25

REVIEW CLIENT AND FAMILY TEACHING 39-1: POSTINTRANIAL SURGERY

REVIEW CLIENT AND FAMILY TEACHING 39-1: POSTINTRANIAL SURGERY

26

providers feel that this affects neurological findings, so acetaminophen is administered instead after a head injury

opioids

27

break in the continuity of the cranium

results from a blow to the head

Skull fracture

28

linear crack w/o any displacement of the pieces

simple fracture

29

broken bone pushed inward toward the brain

depressed fracture

30

bone splintered into fragments

comminuted fracture

31
  • the scalp, bony cranium, and dura mater are exposed
  • create a potential for infection b/c they expose internal brain structures to the environment
  • less likely to produce rapid ICP b/c the opening gives the brain some room to expand as pressure increases

open fracture

32

located at the base of the skull

  • dangerous b/c it can cause edema of the brain near the origin of the spinal cord (foramen magnum), interfere w/ circulation of CSF, injure nerves that pass into the spinal cord, or create a pathway between the brain and middle ear, which can lead to meningitis

Basilar skull fracture

33

This client presents w/:

  • a localized headache
  • bump, laceration, or bruise may be visible on scalp
  • rhinorrhea (leakage of CSF from nose)
  • otorrhea (leaking of CSF from ear)
  • periorbital ecchymosis
  • Battle sign (bruising of the mastoid process behind the ear
  • unequal pupils
  • deformity of skull
  • conjunctival hemorrhages

Skull Fractures

34

Medical and surgical management for clients w/ skull fractures?

  • bed rest
  • observe for s/s of IICP
  • Depressed skull fractures require a craniotomy
  • antibiotics
  • anticonvulsants
  • osmotic diuretics

35

Nursing management for clients w/ skull fractures?

  • examine client to identify signs of head trauma and tests drainage from the nose or ear
  • look for halo sign
  • perform neuro assessments hourly
  • obtain vitals q 15-30 minutes and prepare for possibility of seizures

36

To detect any CSF in a client w/ a skull fracture, the nurse looks for this?

  • it is a bloodstain surrounded by a clear or yellowish stain

Halo sign

37

REVIEW NURSING GUIDELINES 39-1: DETECTING CEREBROSPINAL FLUID IN DRAINAGE

REVIEW NURSING GUIDELINES 39-1: DETECTING CEREBROSPINAL FLUID IN DRAINAGE

38

TRUE OR FALSE?

Trauma to the back can fracture or collapse one or more vertebrae, causing a portion of the bone to injure the spinal cord and interfere w/ the transmission of nerve impulses

True

39

refers to weakness, paralysis, and sensory impairment of all extremities and the trunk when there is a spinal injury above the first thoracic (T1) vertebrae

Tetraplegia

40

weakness or paralysis and compromised sensory functions on both legs and lower pelvis, occurs w/ spinal injuries below the T1 level

Paraplegia

41

What are immediate complications of spinal injury?

  • Respiratory arrest
  • spinal shock

42

loss of sympathetic reflex activity below the level of injury w/i 30-60 minutes of the spinal injury

Spinal shock

43

This client presents w/:

  • immediate loss of all cord functions below the point of injury
  • paralysis
  • hypotension
  • bradycardia
  • respiratory failure
  • bowel and bladder distention develop
  • client does not perspire below the level of injury, causing impairment of temperature control
  • poikilothermia (body temperature of the environment)

Spinal shock

44

exaggerated sympathetic nervous system response in clients with spinal cord injuries above T6

  • can occur at any time after a spinal shock subsides

autonomic dysreflexia

(hyperreflexia)

45

This client presents w/:

  • severe htn
  • bradycardia
  • pounding headache
  • nausea
  • blurred vision
  • flushed skin
  • sweating
  • goosebumps
  • nasal stuffiness
  • anxiety

Autonomic dysreflexia

(hyperreflexia)

46

Common causes of autonomic dysreflexia

  • full bladder
  • abdominal distention
  • impacted feces
  • skin pressure/breakdown
  • overstretched muscles
  • sexual intercourse
  • labor and delivery
  • sunburn below the injury
  • infected ingrown toenail
  • exposure to hot or cold environmental temperature
  • taking OTC depressants

47

if injury is high in the cervical region what can occur?

respiratory failure and death b/c the diaphragm is paralyzed

48

Medical management for clients w/ spine injuries?

Initially:

  • head and neck are immobilized w/ a cervical collar and back support
  • IV line if shock develops
  • Vitals
  • corticosteroids

After the client is stabilized:

  • injured portion of the spine is further immobilized using a cast or brace or surgical intervention
  • traction w/ weights and pulleys is applied to provide correct vertebral alignment and to increased the space b/t the vertebrae
  • surgery

49

Long term management for spinal cord injuries??

  • Functional electrical stimulation (FES)
  • Treadmill training
  • Tendon Transfer Surgery
  • Cell Transplant

50

used to activate paralyzed muscles and prevent muscle atrophy

  • electrodes attach to the quads, hamstrings, and gluteal muscles to help paralyzed legs pedal a bicycle, stand, or walk
  • electrodes attach to the forearm and flexors and extensors of the hand to help the hand open and close to allow grasping of objects, reduce stiffness, maintain/increase ROM, and increase circulation
  • can be used to restore bladder circulation
  • improves breathing

Functional Electrical Stimulation (FES)

51

weight-supported ambulation

  • only suitable for clients w/ an incomplete spinal cord injury (some remaining connections b/t the spinal cord and brain)
  • increases function w/i the remaining connections

Treadmill training

52

REVIEW NURSING PROCESS FOR THE INITIAL CARE OF THE CLIENT W/ SPINAL TRAUMA (PG. 676)

REVIEW NURSING PROCESS FOR THE INITIAL CARE OF THE CLIENT W/ SPINAL TRAUMA (Pg. 676)

53

REVIEW CLIENT AND FAMILY TEACHING 39-2: HALO-VEST MANAGEMENT

REVIEW CLIENT AND FAMILY TEACHING 39-2: HALO-VEST MANAGEMENT

54

What are the 2 types of spinal root compressions?

  1. intramedullary lesions: involve the spinal cord
  2. extramedullary lesions: involve tissues surrounding the spinal cord

55

displacement caused by stress from poor body mechanics, age, or disease putting pressure on the nearby nerves

slipped disk

56

This client presents w/:

  • weakness
  • paralysis
  • paresthesia
  • feeling of pain down the buttocks and into the posterior thigh and leg
  • pain that increases when straining, coughing, or lifting a heavy object
  • walking and sitting become difficult

spinal root compression

57

Medical management for clients w/ spinal root compression?

  • conservative therapy is done first
  • herniated cervical disk (as inflammation subsides, the client wears the collar or brace intermittently when walking or sitting)
  • bed rest w/ firm mattress and bed board
  • skin traction to for alignment
  • Hot, moist packs
  • skeletal muscle relaxants (carisoprodol and chlorzoxazone)

58

When taking skeletal muscle relaxants or a sedative, what should the client avoid doing?

Driving or operating equipment

59

Nursing management for clients who've had spinal surgery?

  • use firm mattress and bed board to support spine and promote alignment
  • maintain bed rest and place client in semi-fowler's position w/ knees and head slightly elevated to relieve lumbosacral pain
  • apply halo-vest
  • intermittent pelvic and skin traction
  • remind client to roll from side to side w/o twisting the spine
  • when client is getting out of bed, ensure proper body mechanics
  • avoid extreme hyperextension of the neck and side-to-side movement of the head
  • administer muscle relaxants and analgesics
  • apply moist heat no longer than 20 minutes but repeat several times a day

60

The proper application and use of traction?

  • the prescribed amount of weight must be used
  • traction weights must hang above the floor
  • ropes must move freely through the pulley grooves
  • the client's position must be in line w/ the pull of the traction apparatus

61

REVIEW NURSING GUIDELINES 39-2: NURSING CARE AFTER SPECIFIC SPINAL SURGERIES

REVIEW NURSING GUIDELINES 39-2: NURSING CARE AFTER SPECIFIC SPINAL SURGERIES

62

Nursing interventions after spinal surgery?

  • monitor vitals
  • assist client to perform hourly deep-breathing exercises while awake but avoid coughing
  • examine the dressing for CSF leakage or bleeding
  • assess neurovascular/circulation in extremities below the area of the surgery
  • report an inability to void or an output of less than 240 ml in 8 hours
  • use a fracture bed pan