Types of Injuries
Severity
GCS
Mechanisms
Nursing Interventions
100
The accumulation of blood between the dura and the arachnoidlayers of the meninges
What is subdural hematoma?
100
Head trauma can be classified into this many classes.
What is three?
100
A standardized, practical tool for assessing the impairment from head injuries
What is Glasgow coma scale?
100
Low impact, which may result in swelling, erythema, laceration, or pain (pt will remain alert and responsive)
What is low velocity?
100
The most important thing the nurse needs to monitor.
What is ABCs?
200
A mild brain injury caused by blunt trauma to the head
What is concussion?
200
Brief disruption in LOC, retrograde amnesia, and headache
What is a concussion?
200
Obedience of command
What is best motor response in the GCS?
200
Occurs when brain stops rapidly (ex. person who falls down – brain hits skull)
What is deceleration?
200
Keep hips flexed at this angle to prevent ICP and allow proper venous blood return.
What is 90 degrees?
300
An accumulation of blood between the dura mater and the skull, can be caused by impact to the temporal areas of the brain
What is epidural hematoma?
300
Patient with a Glasgow Coma Scale 3-8 would be classified as this.
What is severe head trauma?
300
A lack of opening of eyes to any stimulus, a lack of sound even with painful stimuli, abnormal extension, extension of arm at elbow usually with adduction and internal rotation of arm at shoulder
What is a GCS score of 3?
300
High impact, this occurs with motor vehicle accidents or falls greater than the pt’s height, careful evaluation to rule out life-threatening issues
What is high velocity?
300
Keep HOB at this angle to reduce ICP and risk of pneumonia?
What is 30 degrees?
400
The accumulation of blood in the parenchyma of brain tissue, can be caused by uncontrolled hypertension
What is intracerebral hematoma?
400
Glasgow Coma Scale 13-15, No or very brief loss of consciousness (LOC), Normal physical examination, Minor soft tissue injuries
What is mild head trauma?
400
Eyes open with spontaneous response to verbal command; verbal response is appropriate orientation, conversant, correct identification of self, place, year, month; motor response is obedient to command
What is a GCS score of 15?
400
Occur when the force impacting the head does so in a nonlinear way, with the consequence being shearing forces exerted throughout the brain
What is rotational injuries?
400
Administer this before suctioning the patient.
What is oxygen?
500
A brusing of soft tissue, considered moderate to severe
What is contusion?
500
This can occur 2 weeks to 2 months with mild head trauma and symptoms include persistent headache, lethargy, personality and behavioural changes, short attention span, decreased short-term memory, and changes in intellectual ability.
What is post-concussion syndrome?
500
Eyes open: Lack of opening of eyes to painful stimuli but opening to pain Best verbal response: inappropriate or disorganized use of words e.g. cursing, lack of sustained conversation Best motor response: abnormal flexion, flexing of arm at elbow and pronation, making a fist
What is a GCS of 8?
500
These types of objects may also cause shock waves to be transmitted throughout the brain
What is projectile objects?
500
Nursing activities should be _____ to allow patient recovery time.
What is spaced out?
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