TBI's
Interventions
Nursing Diagnosis
Medications
MSCC
100
A simple clean break, impacted area of bone bends inward and area around it bends outward. Most common type of head injury.
What is a linear fracture?
100
An assessment that indicates behavior changes and disorientation
What is Glascow Coma Scale?
100
ICP of 25mmHg, Sp02 86%, BP 170/90, pt. is restless
What is ineffective tissue perfusion?
100
Used IV to treat acute cerebral edema
What is Mannitol (Osmitrol)?
100
Falls and Motor Vehicle Accidents
What is the most common causes of TBIs?
200
A shaky movement of the brain, patient may lose consciousness.
What is a concussion?
200
Elevate HOB, avoid extreme flexion/extension of head, maintain patent airway, provide calm and restful environment.
What is to prevent an increase in ICP?
200
Reduced LOC, depressed cough reflex, HOB at 30 degrees.
What is Risk for Aspiration?
200
Analgesic used to control pain and restlessness, use if client is receiving ventilation (Drug Class)
What is opioids?
200
Second most common cause of TBI's
What is acts of violence & sports?
300
Bone is pressed inward, into brain tissue, to at least the thickness of the skull.
What is a depressed fracture?
300
Application of hypothermic blanket, sponge bath, or administration of Tylenol.
What is treatment of fever?
300
Increased ICP, altered mental status, dec. HR, severe HTN, widened pulse pressure.
What is risk for injury?
300
Used prophylactically to prevent or treat seizures that can occur.
What is Phenytoin (Dilantin)?
300
Summer, Spring, Evenings, Nights, and Weekends
What is when TBIs occur most?
400
A bruising of the brain tissue, most commonly found at the site of impact.
What is a contusion?
400
Side rails up, padded bed rails, and oxygen at bedside.
What is seizure precaution?
400
Decreased LOC, imposed bed rest, physical injury from accident.
What is impaired physical mobility?
400
Used to induce a barbiturate coma to decrease cerebral metabolic demands.
What is Pentobarbital (Nembutal)?
400
Force produced by a blow to head.
What is a direct injury?
500
Actual tearing of the cortical surface vessels, which may lead to secondary hemorrhage.
What is a laceration?
500
Emergency treatment provided during this time frame, especially for epidural hematomas, decreases the morbidity and mortality rates associated with these conditions.
What is 1hr "Golden Window"?
500
Abrupt changes in health status, placed in a hospital environment, and uncertain about future.
What is anxiety?
500
Used to reduce cerebral edema, use with caution in patients with DM, hypertension and glaucoma.
What is Corticosteroids?
500
Where damage most commonly occurs.
What is frontal & temporal lobes?
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