College aantekeningen
neuro shock and burn
- Vak
- Instelling
neuro shock and burn nur 265
[Meer zien]Voorbeeld 3 van de 22 pagina's
Voorbeeld 3 van de 22 pagina's
In winkelwagen
In winkelwagen
gesponsord bericht van onze partner
Verkoper
Volgen
courtneyfocht
Voorbeeld van de inhoud
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)
Voordelen van het kopen van samenvattingen bij Stuvia op een rij:
Verzekerd van kwaliteit door reviews
Stuvia-klanten hebben meer dan 700.000 samenvattingen beoordeeld. Zo weet je zeker dat je de beste documenten koopt!
Snel en makkelijk kopen
Je betaalt supersnel en eenmalig met iDeal, creditcard of Stuvia-tegoed voor de samenvatting. Zonder lidmaatschap.
Focus op de essentie
Samenvattingen worden geschreven voor en door anderen. Daarom zijn de samenvattingen altijd betrouwbaar en actueel. Zo kom je snel tot de kern!
Veelgestelde vragen
Wat krijg ik als ik dit document koop?
Je krijgt een PDF, die direct beschikbaar is na je aankoop. Het gekochte document is altijd, overal en oneindig toegankelijk via je profiel.
Tevredenheidsgarantie: hoe werkt dat?
Onze tevredenheidsgarantie zorgt ervoor dat je altijd een studiedocument vindt dat goed bij je past. Je vult een formulier in en onze klantenservice regelt de rest.
Van wie koop ik deze samenvatting?
Stuvia is een marktplaats, je koop dit document dus niet van ons, maar van verkoper courtneyfocht. Stuvia faciliteert de betaling aan de verkoper.
Zit ik meteen vast aan een abonnement?
Nee, je koopt alleen deze samenvatting voor €8,89. Je zit daarna nergens aan vast.
Is Stuvia te vertrouwen?
4,6 sterren op Google & Trustpilot (+1000 reviews)
Afgelopen 30 dagen zijn er 62774 samenvattingen verkocht
Opgericht in 2010, al 15 jaar dé plek om samenvattingen te kopen