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Nur 265 advanced Medsurg Exam 3
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Nur 265 Advanced Medsurg Exam 3
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Galen College of NursingNur265 Advanced Medsurg
Exam 3 (Unit 7 Ch 38, 39, 40, 41 Unit 8 Ch 23, 32, 34, 20)
Medical Surgical Nursing: Ignatavicius, Workman, Rebar, Heimgarterner 10th edition
Prof Angoma
- Cranial nerve 3,4,6= PEERLA
- Cranial Nerve 2 =vision
- Normal pupils size= 3mm
Categories of brain injury = Direct, coup & counter coup; closed injury; open injury, primary and secondary
If brain WITHOUT O2 6-8mins= brain begins to die!!!!
Counter coup hit skull internally forward and back
In motor vehicle accident unless car is on fire DO NOT move patient unless paramedic
Brain injury –if alcoholic fell- subdural hematoma
Open TBI – skull is open ,fractured or pierced w/ penetrating object (dura and brain compromised ; ex. contusion, Basilar (CSF eyes, nose,
ears
Closed TBI-skull intact; nowhere for blood to go , ex- concussion
Glascow Coma scale= highest best score 15; 8 intubate; 3 lowest score ; Report any decline change in GCS score to HCP
Mild GCS 13-15- feeling dazed and loss of consciousness for us to 30mins or loss of memory for events before accident or
focal neuro deficits ( loss of consciousness) keep them up ; no melatonin; can give Tylenol )
-risk – athletes , kids, elderly (vision changes examples glaucoma (peripheral), macular degeneration (central vision)
Moderate GCS-9-12 with up to 6hrs loss of consciousness – post traumatic amnesia up tot24 hours
Severe GCS 3-8 – icu greater than 6 hours loss consciousness; critical care, have focal and diffuse injuries brain tissue
S/S= amnesia at time injury, headache, dizzy, seizure, Loss of consciousness, sleepy, drowsy, restless, irritable,
disorientation, confusion, scalp bruising or tenderness, personality changes, diplopia, gait changes
Page 917 key features of MILD traumatic brain injury; Physical findings= retrograde amnesia, dazed, stunned, LOC less than
30mins, headache, N/V, balance gait probs, Dizzy, Visual probs, fatigue, sensitivity to light & noise; Cognitive findings= feels mental
foggy, slowed down, concentrating, remembering difficulty, amnesia about events around injury Sleep disturbances= drowsy,
sleeping less or more than usual, trouble sleeping; Emotional Changes= irritable, sad, nervous, more emotional, depressed
Page 915 Traumatic brain Injury= brain injury sit he 5th leading cause of death in elderly; 65-75 age group 2 nd highest incidence in
brain injury of all age groups; falls & motor vehicle crashes are most common causes of brain injury; factors that contribute high
mortality= falls causing subdural hematoma (closed head injuries) ; poorly tolerated systemic stress (high stimulus environment);
medical complications. Hypotension, hypertension, cardiac probs; decreased protective mechanisms, which make patients
susceptible to infections; decreased immunological competence, which is further diminished by brain injury.
Nursing interventions – first priority assessment of airway breathing and circulation; spinal precautions (stabilize spine) , Vs,
Full nuero assessment, prevent secondary brain injury; LOG ROLL , have baseline, limit visitors few visitors
Nursing interventions- ABC's, nuero assessment (baseline); Glascow coma scale Map needs to be 65 ; stabilize BP, dim light,
NA down- risk for seizure; normal body temp (hypothermia=shivering increases ICP), log roll (w/ 2 people), limit visitors,
-If map less than 60 cerebral edema
Halo- CSF leakage= clear drainage from nose (paper towel under nose as it dries GLUCOSE looks yellow/clear) means brain injury
Primary brain injury -occurs at time of injury
Secondary brain injury = process that occurs after initial injury ex. MAP less than 70, hypoxia, intracranial hypertension, cerebral
edema
------------------------------------------
Concussion- (closed TBI) violent jarring causing diffuse microscopic injury to brain
S/S- change in LOC, headache, change in personality, retrograde amnesia at time of injury, NO runny nose, NO drainage from
nose or ear
Causes- shaking baby syndrome , fall from elderly, car accident = temp nuero impairment,
Page 921 PT & family education mild brain injury= for headache give acetaminophen every 4hrs PRN; Avoid sedative, sleeping pills,
no alcoholic beverages for 24hrs after TBI, NO strenuous activity for 48 hrs; awareness of balance disturbances ( monitored assistant
movement), if any of these S/S occur tell HCP > Seizure, severe worsening headache, persistent N/V, blurred vision, clear drainage
from nose or ear, increased weakness, slurred speech, progressive sleepiness, unequal pupil size
-Loss consciousness for 30mins symptoms last 30mins
Post concussion syndrome =last months
S/S= amnesia, disorientation, behavior and personality changes, lethargy , diplopia
Dx- MRI, CT
, no leakage from nose ( bad sign , no sleep meds, no narcotics) can use tylenol not NSAID can cause bleeding;
Amnesia at time of injury
-----------------------------------------
Contusion-(open TBI) injury more serious; gross structural injury w/ skull fracture; worse than concussion
Cause- Coup & counter coup ,
S/S- bruising around eyes, periorbital ecchymosis,battle sign (behind ears), expressive aphasia (frontal) vision problem
(occipital)
Skull fracture- break in continuity of skull or suture line
2 types = open vs closed
S/S= Rhinorrhea, Otorrhea, Halo test, Periorbital ecchymosis, Battle sign, cranial nerve damage
Skull fracture open –non depressed irrigated ; antibiotics let skull heasdache personality changes battle sign , perioribtal
ecchymosis
Non depressed – observe and antibiotics
Skull fracture- depressed- surgical repair
Skull fracture closed personality changes
Basilar skill fracture– how close to brain stem= rhinorrhea from CSF and ear
S/S-change in LOC , behavior change, personality changes,
Page 921 Mild brain injury patient education= for headache give TYLENOL every 4hrs PRN, Avoid giving sedative, sleeping pills,
alcoholic beverages for 24hrs after TBI unless PCP instructs otherwise; Do not engage in strenuous activity for at least 48hrs; balance
disturbances are safety concern caregiver should provide monitored or assisted movement; continue to follow up w/ PCP
IF the these symptoms occur go back to ED or call 911= seizure; severe, worse headache; persistent severe N/V; blurred vision,
clear drainage from ear or nose, increase weakness, slurred speech, progressive sleepiness, unequal pupil size
Page 916 Mild Traumatic Brain injury Causes= blow to the head, transient confusion or feeling dazed or disoriented and one or
more of these conditions 1. possible Loss of Consciousness up to 30mins 2.loss of memory of events immediately before & after
accident 3. focal neurological deficits (may or may not be transient ; Loss of consciousness doesn’t have to occur to dx MTBI; NO
evidence of brain damage on CT or MRI. Symptoms=headache , dizziness, changes in behavior; symptoms usually resolve in 72hrs,
symptoms may presist and last days weeks,, months; persistent MTBI are referred to as Postconcussion syndrome
-------------------------------------------------
Meningitis-inflammation of meninges
Viral meningitis- most common, HSV-2, VZV; nuero defects temp; resolves as decrease in inflammation; + glucose, CSF clear
Fungal meningitis -Crytococcus neoformans AIDS, HIV
Bacterial meningitis-( streptococcus pneumoniae, Neisseria (meningococcal meningitis is medical emergency 24hrs lethal, highly
contagious occurs in college dorms, prison, barracks= NUCHAL rigidity ;; neg glucose in CSF; Droplet precaution; CSF cloudy;
blood culture 1st then give antibiotics within 30mins of admission
Droplet precautions-Surgical mask, goggles, single room; PIMP= Pertussis, influenzas, bac. meningitis, pneumonia
Cause- bacteria (worse bad news ), virus (very common), fungus, trauma, autoimmune
Risk factors- skull fractures, brain , spine surg, sinus infections, nasal sprays, compromised immune system
Dx-CT , lumbar puncture, CSF ( cloudy, +proteins, increase WBC, decreased glucose
Pre Lumbar puncture= Empty bladder, Intra LP= round back (knees to chest); Post LP= monitor dressing (clear fluid=CSF report)
Transmission- crowded living area college or prisons; Droplet precaution for bacterial meningitis)
S/S= sudden fever, headache, nuchal rigidity, mild lethargy; deteriorated LOC, photophobia, agitation + kurnig sign, +
Budzinski sign; red, macular rash, w/meningococcal meningitis, abd , chest pain w/ viral meningitis, lethargic; …..think 3 H’s =
Headache, photophobia, Hard stiff neck, High temp (fever);
S/S Report to HCP = + Kurnig (Krinkle =lay flat lift 1 leg PAINFUL) + Budzinski(Beach chair; fold up like beach chair)
Complication= seizure, coma and death
Nursing intervention- VS and nuero every 4hrs, assess increased ICP, seizure precautions, cranial nerve test, peripheral
vascular status, isolation precaution, urine stool precaution ( viral meningitis); resp isolation (pneumococcal meningitis),
elevate HOB 30 degrees, avoid neck flexion, avoid extreme leg flexion, low stimulus, restrict visitors, admin analgesics
(Tylenol) and antibiotics, log roll, Mannitol (assess for pulmonary edema), intubation (pre & post ABG);
Meds- mannitol (assess lungs complication pulmonary edema)= crackles report to HCP
Teach- prevent w/ meningococcal vaccine
Complication- seizures, clot, septic shock, visual impairment, deafness, paralysis, hydrocephalus
Page 867 Key features of Meningitis= Decreased LOC, disorientation to person , place, time; pupil reaction and eye movements (
Photophobia ( sensitive to light), Nystagmus( repetitive uncontrolled movement); Motor response hemiparesis, hemiplegia,
decreased muscle tone, cranial nerve dysfunction, memory changes, short attention span, personality behavior changes, severe
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