Class notes
neuro shock and burn
- Course
- Med Surg Nur 265
- Institution
- Galen College Of Nursing
neuro shock and burn nur 265
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MAP = DP + 1/3 (SP-DP)
Unit 7 - neuro DP + 1/3 (PP)
GCS: SBP + (2 x 10 or less – emergency attn
needed
<8 intubate
Damage to
Posturing: midbrain/pons
Abnormal
Decorticate posture – flexor
Decerebrate posture –
extensor
Traumatic Head Injury:
Death usually occurs w/ in 3 points:
imm. after injury, 2 hrs post-injury, 3 wks post-
injury **young
Brain injury depends on force, type, location male &
(ICH, epidural hematoma, SDH) elders!
MVC/MVA & falls are the most common reasons
for TBI/THI
**always ask baseline mental status*
Restless = patient getting worse
Primary: occurs @ time of injury & results r/t physical stress Types: blunt force trauma/direct blow
to head
w/in tissue caused by blunt force Indirect from brain being jarred against
interior of skull
GCS class for TBI: *change of 2 pts NOTIFY MD
Open TBI: skull is fractured/pierced by penetrating objected. Coup-countercoup
– GCS 13-15
Mild Integrity 3-8 coma
of dura & brain compromised.
Concussion/mild TBI – feeling dazed &
Closed TBI: integrity of skull not comprised. Blunt vs. Penetrating primary vs.
possible LOC for up to 30 mins/loss of
secondary
memory
Closed vs. Open focal vs. diffuse
for events before accident/focal
Hemorrhagic vs. non-hemorrhagic
neurological
deficits. Symptoms usually resolved w/in
72 hrs. Consequences: physical, cognitive, financial,
No evidence of brain damage emotional & Direct vs. indirect
Sx: H/A, N/V, fatigue, foggy, visual probs.
Expected findings:
Mod – GCS 9-12 w/ up to 6 hr. LOC Amnesia H/A
Post traumatic amnesia may last up to 24 Dizziness
hrs LOC
Short term hosp stay Seizure Scalp bruising
Restless/irritable
Severe – GCS 3-8 w/ 6+ hrs LOC Diplopia
Usually require treatment in ICU & have Disorientation
focal & Personality changes
diffuse injuries to brain tissues, blood Dolls eyes (turn pt head side to side & eyes go
w/ head)
Vessels &/or ventricles. Possible CSF leak.
HIGH RISK for secondary brain injury:
, Secondary Brain injury:
Occurs after initial injury/while trying to recover & neg. influences pt outcome (ex. Meningitis)
Most common: Hypotension (MAP <70), hypoxia (p02<80); Intracranial HTN, IICP
Cerebral edema **good MAP 70-100**
Hypotension r/t shock. Low blood flow + hypoxemia = cerebral edema
Damage to brain r/t Low 02 & glucose.
Nursing Intervention:
First: ABC!
Drainage from
Spinal precautions; VS; Full neurologic assessment; prevent secondary brain injury
nose/ears – educate-
**EMERGENCY – pulse/BP VERY HIGH or VERY LOW**
send results to lab
Goals: Halo sign: asap
Patient airway! Normal temp
Adequate CPP Skin integrity
Fl/Electrolyte balance Prevent secondary injury
Adequate nutrition Prevent sleep deprivation
Concussion
Violent jarring that results in diffuse/microscopic injury to brain
mild
Causes: MVA, falls, shaking
Leading to: temp. neurological impairment w/ completely recovery usually in short time
Post-concussion syndrome: can last a few months, amnesia, disorientation, LOC, H/A,
behavior/personality changes. Lethargy & diplopia – GCS can be 13, 14, 15. NORMAL TO LOSE
CONSCIOUSNESS & HAVE AMNESIA, NAUSEA, H/A
Cheyne-stokes: rapid, fast breathing
Biot’s: normally seen in meningitis,
sever Contusion: more serious than concussion. Bruising @ brain tissue abnormal breathing pattern
e Results: gross structural injury Caused by blunt force trauma
possible skull fx ** worry about ICP
Coup or contra coup or coup contrecoup (site of impact = coup, opposite = contrecoup)
*WATCH NEURO & ICP!*
S/S depends on severity & location
Skull fracture: break in continuity of skull/separation @ a suture line
sever Open vs. closed
e Basilar – potentially serious r/t proximity of brain stem & internal carotid artery
S/S depends on location & severity Depressed fx
Rhinorrhea – CSF leak from nose Linear fx – no tx unless brain tissue
underneath damaged
Otorrhea – CSF leak from ear
Halo test “Bulls eye”; glucose dipstick
Periorbital ecchymosis – racoon eyes
Battles sign – periocular ecchymosis – bruising of mastoid process
Cranial nerve damage
R/f infx r/t CSF leak
Laceration (closed): tearing, leads to secondary hemorrhage, cerebral edema, inflammation
Diffuse axonal injury (closed): survivors require LTC. Immediate coma; impaired cognitive
functioning.
Normally from high speed injury
Hydrocephalus: reabsorption/blockage of CSF. Leads to ICP.
Brain herniation:
, Uncus: dilated nonreactive pupils, ptosis, LOC
sever
Central: down brain stem, Cheyne-stokes, pinpoint & nonreactive pupils, Hemodynamic
e
instability
**notify MD immediately!**
Hemorrhages:
Epidural hematoma: arterial bleed between dura & inner skull. r/t fx of temporal lobe.
“lucid intervals” pt awake/talking then unconscious.
Subdural hematoma: Highest mortality rate! Slow venous bleed – beneath dura & above arachnoid
r/t Laceration.
Acute SDH – w/in 48 hrs
Most
Subacute SDH – 48 hrs to 2 weeks
common
in 16-21 Chronic SDH – 2 weeks to several months
yo **Loss of consciousness w/ SDH or epidural hematoma = neuro emergency!!**
Meningitis: inflammation of meninges. Causes block of CSF, blood flow & leads to clot
formation.
Treat quickly = good prognosis. **could even be a response to OTC drugs.
Prognosis poor for elderly & infants.
Bacterial: most serious** Highly contagious! Viral: Most
common Deadly if
Causes: meningococci, streptococci & not Causes: herpes simplex, mumps, enterovirus
caught &
Pneumococci Virus causes cerebral vasculitis
tx w/in 24
Bacteria reaches meninges through blood/infx
hrs. Leads to cerebral edema, irreversible
coma, seizures
In ears/sinuses – spreads to cranial & spinal brain abscess & neuro changes
Nerves *know how it spreads. Protect self first. High risk
– jail, dorms,
Close crowds, Etc.*
**meningococcal meningitis = MEDICAL EMERGENCY!
Causes neuro deterioration, hearing loss, or loss of limb Kernig’s sign – pt flat on back, lift
thigh 90* angle = pain
Brudzinski’s sign – supine, lift head, rapidly flex,
involuntary
Flexion w/ knees & ankles.
S/S: fever, chills, nuchal rigidity, Kernig’s sign, Brudzinski’s sign, LOC changes, Photophobia,
Severe H/A, N/V
Petechial rash w/ meningococcal (most severe meningitis) monitor ICP!
Complications: damage to CNS, brain/spinal cord may result in: KNOW DROPLET!!!!
Seizures, septic shock, visual impairment, deafness, paralysis, hydrocephalus
Diagnosis:
Bacterial: Viral: Nursing Interventions:
CSF from LP = cloudy C & S negative Monitor Neuro status & ABCs
CSF pressure WBC freq. VS/Neuro checks Q4hr
Glucose concentration temp monitor & tx; stimuli
Protein levels **SIRS MAY LEAD TO DIC** szs- precautions- anticonvulsants PRN
WBC, RBC counts I&O, DW, DROPLET! Teach visitors.
C&S to ID bacteria monitor for gangrene &
thrombus
Medical tx: Hyponatremia: Conivaptan &
Tolvaptan(severe)
Bacterial – 2 week IV Abx Suspected DI: Vasopressin,
Desmopressin (LT)
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