Types of head injuries
A transient brain injury causing headache, amnesia, dizziness, and possible brief LOC.
What is a concussion?
This is the most important indicator of a head-injured patient's neurologic condition.
What is level of consciousness (LOC)?
Normal ICP is within this range.
What is 5-15 mmHg?
Until proven otherwise, every head-injured patient should be managed as though they also have this injury.
What is a cervical spine injury?
Following an acute C5 SCI, a client has BP 78/42, HR 46, and peripheral vasodilation. This complication results from loss of sympathetic tone.
What is neurogenic shock?
This hematoma classically causes LOC → lucid interval → rapid neurologic deterioration.
What is an epidural hematoma?
This standardized assessment Glascow coma scale evaluates these 3 indicators of neurological status.
What are eye opening, verbal response, and motor response?
According to Monro-Kellie, the skull contains three major components whose total volume must remain relatively constant. Name these components.
What are brain tissue, blood, and CSF?
Position the head this way to facilitate venous drainage and help decrease ICP.
What is HOB 30–45° with the head/neck midline?
After an acute C6 SCI, a client has BP 78/40, HR 44, and warm, vasodilated skin. This vasopressor may be anticipated to restore vascular tone and support blood pressure.
What is norepinephrine?
An older adult develops confusion, lethargy, and memory changes several weeks after a minor fall.
What is chronic subdural hematoma?
Increasing restlessness, worsening headache, nausea and vomiting followed by decreasing LOC should alert the nurse to increase in this.
What is intracranial pressure?
BP rises, pulse pressure widens, and HR decreases in a deteriorating TBI patient.
What is Cushing's response/triad?
These two osmotic therapies may be used to decrease cerebral edema and ICP.
What are hypertonic saline and mannitol?
Weeks after a T4 SCI, a client suddenly develops BP 210/110, HR 48, severe headache, flushing, and diaphoresis. What is the nurses first action?
What is raise the HOB and then performs this priority assessment/intervention?
This injury results from widespread axonal damage and may cause decreased LOC, increased ICP, posturing, and global cerebral edema despite limited outward evidence.
What is diffuse axonal injury?
A patient opens eyes only to pain, makes incomprehensible sounds, and localizes pain. This is the GCS.
What is 9?
MAP is 85 mmHg and ICP is 25 mmHg. calculate the CPP.
What is 60 mmHg?
Name three things that can worsen ICP and should be minimized.
What are suctioning, fever, straining, vomiting, excessive movement/stimulation, increased thoracic/abdominal pressure, or agitation/combative behavior?
A client with a C6 SCI initially breathes independently but 18 hours later develops shallow respirations, a weak cough, and rising PaCO₂. This evolving process explains why the nurse should anticipate intubation.
What is progressive spinal cord edema causing respiratory compromise?
A client was initially unconscious after a head injury, awakened and talked with family, then suddenly becomes unresponsive, vomits, and develops a fixed unilateral pupil. Identify the priority concern.
What is impending herniation?
A client with acute head injury has bilateral flexion of the arms toward the body. Name the posturing type.
What is decorticate posturing?
Hemorrhage, infection or dislodgment are complications of this ICP monitoring device.
What is external ventricular drain?
A patient's ICP suddenly increases to 24 mmHg. Give four immediate nursing priorities to take.
What are reassess neuro status/ICP, maintain HOB 30–45° and midline alignment, ensure oxygenation/ventilation, reduce stimulation, assess, reduce fever, EVD/drainage if present, and notify/escalate care?
A client with a T4 SCI suddenly develops a pounding headache, severe hypertension, bradycardia, and diaphoresis. The nurse should first investigate this most common trigger.
What is bladder or bowel distention?