Chapter 39: Caring for Clients w/ Head and Spinal Cord Trauma Flashcards

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

25

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

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

54

What are the 2 types of spinal root compressions?

intramedullary lesions: involve the spinal cord
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

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

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