NUR 265 Nursing Concepts Test # 3/Adv Med Srg #3 STUDY GUIDE

NUR 265 Nursing Concepts Test # 3 Care of Critically Ill Patients with Neurologic Problems / Chapter 47 (25 questions) Traumatic Brain Injury 1. Contrecoup injury  Coup is an impact to the frontal lobe; countrecoup is the impact to the occipital area from the brain bouncing backwards. 2. Contusion  Bruising of the brain tissue; structural damage 3. Concussion  Shaky movement of the brain; may lose consciousness; retrograde amnesia; NO structural damage.  Client teaching: have pt. woken every 3-4hrs to assess LOC; EXPECT headache, nausea and dizziness for 24hrs, if gets worse or does not subside, go back to hospital; no alcohol, sedatives or sleeping pills, give Tylenol prn every 4hrs; GO BACK TO HOSPITAL IF THESE SYMPTOMS OCCUR: blurred vision, rhinorrhea or ottorrhea, weakness, slurred speech, progressive sleepiness, vomiting, unequal pupil size, and worsening headache. 4. Basilar skull fracture (unique fracture)*  Fracture at base of skull; causes CSF leakage of the nose (rhinorrhea) and the ears (ottorrhea);  Risk for INFECTION r/t direct access to subarachnoid space.  Potential for hemorrhage: Raccoon eyes (bleeding around orbits of eyes) and Battle Sign (bruising behind ears) Hemorrhage (Brain) *All hematomas are potentially life-threatening because they act as space-occupying lesions and are surrounded by edema, thus increasing ICP. 1. Epidural hematoma  Located above dura; primarily an arterial bleed. 2. Subdural hematoma  Located below dura and above arachnoid; primarily a venous bleed.  Slow bleed; acute stage happens within 48hrs. after impact; high mortality rate; usually goes unrecognized.  Earliest sign is a change in personality; Ask pt. if they fell or hit their headhowcheck headput on gloves and palpate. 1 This study resource was shared via CourseH 3. Intracerebral hemorrhage  Can be both venous and an arterial bleed; usually results from a blown aneurysm; causes increased ICP. Increased Intracranial Pressure **Normal ICP: 10-15 mmHg 1. Earliest change:  Change in LOC r/t pressure on frontal lobe, best indicator!!!!  Other early s/s: headache and projectile N/V 2. Cushing’s triad-:  classic, late sign: severe hypertension with widened pulse pressure and bradycardia 3. Pupillary changes :  ovoid pupil: midstage between a normal pupil and a dilated pupil  pupils that are dilated and fixed (‘blown’) r/t pressure exerted onto III cranial nerve. Cranial nerve III directly affects pupils. 4. EOMs diminished- CN III, IV, and VI  EOM: Extra Ocular Eye Movement  These nerves regulate eye muscle movement  Diminished cranial nerves r/t increased pressure on brain stem (where these nerves are located); since pressure moves downward from frontal lobe to brainstem, once pressure gets to this point, it means increased ICP is severe.  Pinpoint and nonresponsive pupils are indicative of brainstem dysfunction at the level of the pons. 5. Papilledema  Choked disk (edema and hyperemia; increased blood flow of optic disk; only seen with an ophthalmoscope) 6. Decorticate and decerebrate posturing  Decorticate: Upper extremeties are flexed inwards at core  Decerebrate: upper extremeties/wrists are tensed outwards at sides; this is more severe than decorticate, indicates more damage to brain. 7. CSF leak- “halo” sign  CSF contains glucose and protein  To assess for CSF leak, obtain gauze to absorb fluid, fluid will scatter outwards forming a “yellowish halo”. 8. Glasgow Coma Scale  Three major areas assessed on scale: Eye opening, motor response and verbal response  Graded from 3-15; 3 being the worst, 15 the best.