NSG 4100: EXAM 4- MUDDY POINTS
Unit 8 Complex Neurological Problems
1. Head trauma – prioritize care, what would require immediate intervention?
what are some causes for head injuries?
o sports, MVCs
o men are more at risk
Basal Skull fracture- “battle sign” (hematoma at ear / bruising over mastoid
bone),
“raccoon eyes” periorbital hematoma
o CSF from ears/nose—> emergency
o Diabetes insipidus- deficiency of antidiuretic hormone-trauma to
pituitary gland
i. Dilute urine (polyuria)
ii. Polydipsia (thirst)
iii. Dehydration
o Headache
Depressed skull fx: requires surgery within 24 hours
Nursing interventions:
o Neuro assessment- GCS scale (GCS<8 —> intubate)
i. GCS 15 max, 8 or less = coma, 3 = unresponsive; 5 = brain
death
ii.
o ABC
You are assessing a patient using the GCS and her eyes open to pain, she is
confused and obeys commands what is her score?
o 12
Patient with a head injury has vital signs 98.6-110-26-128/68, which of the
following vital signs below should concern you after one hour?
o a blood pressure of 156/60, pulse 60, respirations 14
Which is an incorrect statement about a patient with a closed head injury s/p
MVA?
o effects of injury peak about 12 to 24 hours
i. Correct: loss of consciousness associated with stupor and
confusion, deep contusions are more often associated with
hemorrhage and destruction, C patients are more often
,managed medically with the goal of preventing more insults
,
What requires immediate attention for an ED patient who has multiple
injuries from an MVA?
o deviated trachea
2. Traumatic brain injury (TBI) – prioritize care, what would require immediate
intervention?
HOB 30-40
Protect airway
Neuro assessment Ǫ1H,, Doll eyes + good:
o Positive=> eyes moving in the opposite direction of head movement
indicating an intact brainstem function
o Negative=> eyes moving towards the same direction of head
movement indicating severe brainstem dysfunction.
i. Call pcp worsened neuro status
Types of TBI:
Type Description Priority Nursing Actions
Focal bruising, loss of consciousness, Monitor neuro status, prevent secondary
Contusion
peaks 18–36h injury
Epidural (arterial, emergency), Subdural Frequent neuro checks, rapid intervention
Hematomas
(venous) for epidural
Concussion Diffuse injury Monitor ICP, rest, reduce stimulation
Diffuse Axonal Injury
Widespread axonal damage Supportive care, monitor ICP
(DAI)
Focal
o Contusion
i. The brain is bruised and damaged in a specific area because
of severe acceleration-deceleration force or blunt trauma.
The impact of the skull leads to a contusion
ii. Contusions can be characterized by loss of consciousness
associated with stupor and confusion. The effects of injury,
particularly hemorrhage and edema, peak after about 18 to 36
hours.
o Hematomas
i. The nurse is caring for a client in the ED, which client should the
nurse asses first? The client with an epidural hematoma
1. An epidural hematoma results from bleeding between the
dura and the inner surface of the skull and is an active
arterial bleed. This is a medical emergency
ii. A woman with suspected epidural hematoma, who may have
blacked out at home C answers questions appropriately, what
would be the priority nursing action?
1. close monitoring
Diffuse
o Concussions
i. 1st priority /Toes pointed downward
1. Decerebrate
a. The critical care nurse is caring for a client with a
head injury secondary to a motorcycle accident
, who, on morning rounds, is responsive to painful
stimuli and assumes decorticate posturing. Two
hours later, which data would warrant immediate
intervention by the nurse?
i. The client extends the upper and lower
extremities in response to painful stimuli.
1. Extension of the upper and lower
extremities is assuming a decerebrate
posture, which indicates the clients ICP
is increasing
o DAI
A diffuse axonal brain injury (DAI) is a specific type of traumatic brain injury
that can have devastating consequences for victims and their families. Often
caused by sudden, forceful motions, DAIs occur when the brain’s nerve
fibers are damaged after a traumatic incident, such as a car crash, fall, or
assault. Diffuse axonal injuries are one of the most severe forms of brain
damage, leading to long-term cognitive and physical impairments.
Handling the aftermath of a diffuse axonal brain injury poses a life-altering
challenge. When these injuries result from someone’s negligence, seeking
legal counsel with a qualified brain injury lawyer is essential. Brain injuries
are vastly complicated from both a medical and legal point of view and
should not be handled without expert guidance. In this article, we discuss
the implications of diffuse axonal brain injuries, their prognosis and
diagnosis, and how hiring a lawyer can help families recover from these
devastating injuries.
A Diffuse Axonal Injury visualized on an MRI scan. Image: https://www.ajnr.org/
Diffuse axonal brain injuries occur when the connective nerve fibers in the
brain (axons) are torn. After a traumatic impact or jolt to the head, rapid
acceleration and deceleration cause the brain to move and bounce around
inside the skull. This sudden, violent motion can stretch and shear the
axons, causing severe brain damage that impacts cognition, sensory
perception, and motor skills.
Think of the brain as a complex communication network, where axons are
like wires that allow individuals to send and receive messages. In a diffuse
axonal injury, these “wires” are not merely disconnected in one place; the
damage is scattered throughout the entire network, disrupting the brain’s
ability to communicate with itself and function as a cohesive whole.
Unit 8 Complex Neurological Problems
1. Head trauma – prioritize care, what would require immediate intervention?
what are some causes for head injuries?
o sports, MVCs
o men are more at risk
Basal Skull fracture- “battle sign” (hematoma at ear / bruising over mastoid
bone),
“raccoon eyes” periorbital hematoma
o CSF from ears/nose—> emergency
o Diabetes insipidus- deficiency of antidiuretic hormone-trauma to
pituitary gland
i. Dilute urine (polyuria)
ii. Polydipsia (thirst)
iii. Dehydration
o Headache
Depressed skull fx: requires surgery within 24 hours
Nursing interventions:
o Neuro assessment- GCS scale (GCS<8 —> intubate)
i. GCS 15 max, 8 or less = coma, 3 = unresponsive; 5 = brain
death
ii.
o ABC
You are assessing a patient using the GCS and her eyes open to pain, she is
confused and obeys commands what is her score?
o 12
Patient with a head injury has vital signs 98.6-110-26-128/68, which of the
following vital signs below should concern you after one hour?
o a blood pressure of 156/60, pulse 60, respirations 14
Which is an incorrect statement about a patient with a closed head injury s/p
MVA?
o effects of injury peak about 12 to 24 hours
i. Correct: loss of consciousness associated with stupor and
confusion, deep contusions are more often associated with
hemorrhage and destruction, C patients are more often
,managed medically with the goal of preventing more insults
,
What requires immediate attention for an ED patient who has multiple
injuries from an MVA?
o deviated trachea
2. Traumatic brain injury (TBI) – prioritize care, what would require immediate
intervention?
HOB 30-40
Protect airway
Neuro assessment Ǫ1H,, Doll eyes + good:
o Positive=> eyes moving in the opposite direction of head movement
indicating an intact brainstem function
o Negative=> eyes moving towards the same direction of head
movement indicating severe brainstem dysfunction.
i. Call pcp worsened neuro status
Types of TBI:
Type Description Priority Nursing Actions
Focal bruising, loss of consciousness, Monitor neuro status, prevent secondary
Contusion
peaks 18–36h injury
Epidural (arterial, emergency), Subdural Frequent neuro checks, rapid intervention
Hematomas
(venous) for epidural
Concussion Diffuse injury Monitor ICP, rest, reduce stimulation
Diffuse Axonal Injury
Widespread axonal damage Supportive care, monitor ICP
(DAI)
Focal
o Contusion
i. The brain is bruised and damaged in a specific area because
of severe acceleration-deceleration force or blunt trauma.
The impact of the skull leads to a contusion
ii. Contusions can be characterized by loss of consciousness
associated with stupor and confusion. The effects of injury,
particularly hemorrhage and edema, peak after about 18 to 36
hours.
o Hematomas
i. The nurse is caring for a client in the ED, which client should the
nurse asses first? The client with an epidural hematoma
1. An epidural hematoma results from bleeding between the
dura and the inner surface of the skull and is an active
arterial bleed. This is a medical emergency
ii. A woman with suspected epidural hematoma, who may have
blacked out at home C answers questions appropriately, what
would be the priority nursing action?
1. close monitoring
Diffuse
o Concussions
i. 1st priority /Toes pointed downward
1. Decerebrate
a. The critical care nurse is caring for a client with a
head injury secondary to a motorcycle accident
, who, on morning rounds, is responsive to painful
stimuli and assumes decorticate posturing. Two
hours later, which data would warrant immediate
intervention by the nurse?
i. The client extends the upper and lower
extremities in response to painful stimuli.
1. Extension of the upper and lower
extremities is assuming a decerebrate
posture, which indicates the clients ICP
is increasing
o DAI
A diffuse axonal brain injury (DAI) is a specific type of traumatic brain injury
that can have devastating consequences for victims and their families. Often
caused by sudden, forceful motions, DAIs occur when the brain’s nerve
fibers are damaged after a traumatic incident, such as a car crash, fall, or
assault. Diffuse axonal injuries are one of the most severe forms of brain
damage, leading to long-term cognitive and physical impairments.
Handling the aftermath of a diffuse axonal brain injury poses a life-altering
challenge. When these injuries result from someone’s negligence, seeking
legal counsel with a qualified brain injury lawyer is essential. Brain injuries
are vastly complicated from both a medical and legal point of view and
should not be handled without expert guidance. In this article, we discuss
the implications of diffuse axonal brain injuries, their prognosis and
diagnosis, and how hiring a lawyer can help families recover from these
devastating injuries.
A Diffuse Axonal Injury visualized on an MRI scan. Image: https://www.ajnr.org/
Diffuse axonal brain injuries occur when the connective nerve fibers in the
brain (axons) are torn. After a traumatic impact or jolt to the head, rapid
acceleration and deceleration cause the brain to move and bounce around
inside the skull. This sudden, violent motion can stretch and shear the
axons, causing severe brain damage that impacts cognition, sensory
perception, and motor skills.
Think of the brain as a complex communication network, where axons are
like wires that allow individuals to send and receive messages. In a diffuse
axonal injury, these “wires” are not merely disconnected in one place; the
damage is scattered throughout the entire network, disrupting the brain’s
ability to communicate with itself and function as a cohesive whole.
