Print Chapter 39: Caring for Clients w/ Head and Spinal Cord Trauma flashcards - Easy Notecards

← Back to notecard set|Easy Notecards home page

Instructions for Side by Side Printing

Print the notecards
Fold each page in half along the solid vertical line
Cut out the notecards by cutting along each horizontal dotted line
Optional: Glue, tape or staple the ends of each notecard together

To print: Ctrl+PPrint as a list

62 notecards = 16 pages (4 cards per page)

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

front 1 results from a blow to the head that jars the brain	back 1 Concussion
front 2 This client presents w/: a brief lapse of consciousness with temporary disorientation headache blurred or double vision emotional irritability dizziness	back 2 Concussion
front 3 Medical management for clients w/ concussion	back 3 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
front 4 Nursing management for clients w/ concussion	back 4 neurologic assessment (observe for IICP) instruct client and family to return to ER if s/s of IICP occur

front 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	back 5 Contusion
front 6 when head is struck directly with a contusion	back 6 croup injury
front 7 when dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull	back 7 Contrecoup injury
front 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)	back 8 Contusion

front 9 What is performed to rule out or confirm a skull fracture?	back 9 Skull radiography
front 10 Medical management for client's with a contusion?	back 10 manage client's vital functions with drug therapy and mechanical ventilation
front 11 Nursing management for client's with contusion?	back 11 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
front 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	back 12 Cerebral Hematoma

front 13 Medical management for clients w/ a cerebral hematoma	back 13 a rapid change in LOC and signs of uncontrolled IICP indicate a surgical emergency
front 14 Surgical management for clients w/ a cerebral hematoma?	back 14 trephining craniotomy craniectomy cranioplasty
front 15 surgery that consists of draining holes (burr holes) in the skull to relieve pressure, remove clots in brain, and stop bleeding	back 15 trephining
front 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	back 16 craniotomy

front 17 removal of a portion of a cranial bone	back 17 craniectomy
front 18 repair of a defect in a cranial bone	back 18 cranioplasty
front 19 complications associated w/ intracranial surgery	back 19 cerebral edema infection neurogenic shock fluid and electrolyte imbalance venous thrombosis (esp. in arms and legs) IICP seizures leakage of CSF stress ulcers hemorrhage
front 20 What should the nurse monitor for when administering mannitol	back 20 crystal formation an in-line filter is recommended to use during the administration of 15%, 20%, and 25% solutions

front 21 Nursing management for clients hematomas?	back 21 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
front 22 Pre-op care for clients getting a cranial surgery	back 22 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
front 23 Post-op care for clients getting a cranial surgery	back 23 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
front 24 REVIEW NURSING CARE PLAN 39-1: CARE OF THE CLIENT UNDERGOING INTRACRANIAL SURGERY	back 24 REVIEW NURSING CARE PLAN 39-1: CARE OF THE CLIENT UNDERGOING INTRACRANIAL SURGERY

front 25 REVIEW CLIENT AND FAMILY TEACHING 39-1: POSTINTRANIAL SURGERY	back 25 REVIEW CLIENT AND FAMILY TEACHING 39-1: POSTINTRANIAL SURGERY
front 26 providers feel that this affects neurological findings, so acetaminophen is administered instead after a head injury	back 26 opioids
front 27 break in the continuity of the cranium results from a blow to the head	back 27 Skull fracture
front 28 linear crack w/o any displacement of the pieces	back 28 simple fracture

front 29 broken bone pushed inward toward the brain	back 29 depressed fracture
front 30 bone splintered into fragments	back 30 comminuted fracture
front 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	back 31 open fracture
front 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	back 32 Basilar skull fracture

front 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	back 33 Skull Fractures
front 34 Medical and surgical management for clients w/ skull fractures?	back 34 bed rest observe for s/s of IICP Depressed skull fractures require a craniotomy antibiotics anticonvulsants osmotic diuretics
front 35 Nursing management for clients w/ skull fractures?	back 35 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
front 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	back 36 Halo sign

front 37 REVIEW NURSING GUIDELINES 39-1: DETECTING CEREBROSPINAL FLUID IN DRAINAGE	back 37 REVIEW NURSING GUIDELINES 39-1: DETECTING CEREBROSPINAL FLUID IN DRAINAGE
front 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	back 38 True
front 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	back 39 Tetraplegia
front 40 weakness or paralysis and compromised sensory functions on both legs and lower pelvis, occurs w/ spinal injuries below the T1 level	back 40 Paraplegia

front 41 What are immediate complications of spinal injury?	back 41 Respiratory arrest spinal shock
front 42 loss of sympathetic reflex activity below the level of injury w/i 30-60 minutes of the spinal injury	back 42 Spinal shock
front 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)	back 43 Spinal shock
front 44 exaggerated sympathetic nervous system response in clients with spinal cord injuries above T6 can occur at any time after a spinal shock subsides	back 44 autonomic dysreflexia (hyperreflexia)

front 45 This client presents w/: severe htn bradycardia pounding headache nausea blurred vision flushed skin sweating goosebumps nasal stuffiness anxiety	back 45 Autonomic dysreflexia (hyperreflexia)
front 46 Common causes of autonomic dysreflexia	back 46 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
front 47 if injury is high in the cervical region what can occur?	back 47 respiratory failure and death b/c the diaphragm is paralyzed
front 48 Medical management for clients w/ spine injuries?	back 48 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

front 49 Long term management for spinal cord injuries??	back 49 Functional electrical stimulation (FES) Treadmill training Tendon Transfer Surgery Cell Transplant
front 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	back 50 Functional Electrical Stimulation (FES)
front 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	back 51 Treadmill training
front 52 REVIEW NURSING PROCESS FOR THE INITIAL CARE OF THE CLIENT W/ SPINAL TRAUMA (PG. 676)	back 52 REVIEW NURSING PROCESS FOR THE INITIAL CARE OF THE CLIENT W/ SPINAL TRAUMA (Pg. 676)

front 53 REVIEW CLIENT AND FAMILY TEACHING 39-2: HALO-VEST MANAGEMENT	back 53 REVIEW CLIENT AND FAMILY TEACHING 39-2: HALO-VEST MANAGEMENT
front 54 What are the 2 types of spinal root compressions?	back 54 intramedullary lesions: involve the spinal cord extramedullary lesions: involve tissues surrounding the spinal cord
front 55 displacement caused by stress from poor body mechanics, age, or disease putting pressure on the nearby nerves	back 55 slipped disk
front 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	back 56 spinal root compression

front 57 Medical management for clients w/ spinal root compression?	back 57 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)
front 58 When taking skeletal muscle relaxants or a sedative, what should the client avoid doing?	back 58 Driving or operating equipment
front 59 Nursing management for clients who've had spinal surgery?	back 59 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
front 60 The proper application and use of traction?	back 60 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

front 61 REVIEW NURSING GUIDELINES 39-2: NURSING CARE AFTER SPECIFIC SPINAL SURGERIES	back 61 REVIEW NURSING GUIDELINES 39-2: NURSING CARE AFTER SPECIFIC SPINAL SURGERIES
front 62 Nursing interventions after spinal surgery?	back 62 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